A sincere effort has been made to make the book simple. diagnosis and management of mental disorders. A major portion of these textbooks is devoted to the psychiatric practice in western countries and is not practically oriented. R. “Psychiatry for General Practitioners” is an attempt to rectify most of these lacunae. There have been many new advances in the causation. easy. M. All suggestions are welcome and will be duly acknowledged. being an allied branch of Medicine.C. classification.S. comprehensive and practically oriented. We record our sense of indebtedness and gratitude to the contributors and general practitioners for their constant inspiration and useful suggestions. Jiloha Dr. symptomatology.Preface
Psychiatry. We hope that this book will be successful in fulfilling its aims. Dr. The present book. The textbooks on psychiatric practice as applicable to Indian setting are few. It also includes important common mental health problems faced by a General Practitioner in day today practice. Most of these textbooks do not contain the important aspects of psychiatry required by a General Practitioner. Bhatia
. is undergoing rapid changes.

With the population of more than 100 crores. The fact that there are only 1 or 2 psychiatrists per million populations in India there is a need for involving primary care doctors in the identification and management of common mental health problems. there are only 3000 psychiatrists in the country.40.40. Situation is similar to other parts of the country. adjustment disorders. The National Mental Health Programme which came in 1982. the services provided by a handful of government run hospitals and a few psychiatrists in private practice. A recent Need Assessment Survey (NAS) conducted by Delhi Mental Health Authority (DMHA) reveals that: “Delhi has an estimated population of about 1. Situation is not any better in the city of Delhi. approximately 14 lac persons in Delhi are in need of psychiatric help and out of these 1. Out of these about 1% suffer from schizophrenia and other psychotic disorders which are considered to be serious ailments while others suffer from depression.00. are not adequate. With the recent exodus of psychiatrists. about 25% of the general population suffers from psychiatric illnesses. substance abuse and other related disorders. As per the WHO Report of 2000. There are only 452 psychiatric beds for Delhi population. The essential focus of these discussions has been the enormity of the mental health problems and the available technical know how in the country.1
Introduction
Organisation of mental health services in the country has remained a subject matter of discussion in various workshops and seminars.000.
. strives to bring mental health services to each and every needy person. Thus. Delhi is left with around 140 psychiatrists to take care of these patients. Considering the magnitude of psychiatric disorders. It could only be possible if mental health services are integrated with the general health services and with the community participation in the delivery of these services.000 are suffering from severe mental disorders. The discrepancy between the magnitude of psychiatric problems in the general population and the number of psychiatrists available is quite evident. There are five Government Hospitals providing psychiatric services (including one psychiatric hospital) and 10 licenced psychiatric nursing homes to look after their indoor needs. anxiety.

S. Ram Manohar Lohia Hospital (RML).).C. mood disorders. schizophrenia. Safdarjung Hospital and VIMHANS.B. We have also invited senior and experienced psychiatrists in private sector to participate in this programme. drugs and alcohol problems. Training of general practitioners in psychiatry under the National Mental Health Programme is one step towards effective delivery of mental health services to the general population. Pant Hospital has been identified by the Government of India as one of the centres to train the general practitioners under this programme.2
Psychiatry for General Practitioners
As observed earlier. We have selected the topics of the book keeping in mind their utility in day to day practice. We have drawn teaching faculty from various medical institutes of the city including All India Institute of Medical Sciences (AIIMS).M. We hope this book will disseminate the desired knowledge and confidence among the general practitioners in handing mental health problems and achieving the goal of delivering mental health services to each and every patient in need of it. The department of psychiatry G. related to common problems encountered in the clinics such as depression. This programme was conducted for two years to train 800 general practitioners. childhood behavioural disorders and others. anxiety disorders. University College of Medical Sciences (U.
. the training in psychiatry during undergraduate medical education is inadequate to identify and treat the mental illnesses.

the problems of releasing information to the court. which is Greek for healer. When the focus is on different cultures.
. (b) Geriatric Psychiatry: The branch of psychiatry that deals with disorders of old age. Psyche was a mortal woman made immortal by Zeus. (e) Social Psychiatry: In Psychiatry. The different branches in Psychiatry are:(a) Child Psychiatry: The science of healing or curing disorders of the psyche in children (i. the stress laid on the environmental influences and the impact of the social group on the individual. memory etc. treatment and prevention of mental abnormalities and disorders. (d) Forensic Psychiatry (Legal Psychiatry): Psychiatry in its legal aspects. commitment of the mentally ill. (c) Community Psychiatry: The branch of psychiatry concerned with the provision and delivery of a coordinated program of mental health care to a specified population. penology. The emphasis is on aetiology. Psychology: The science that deals with the mind and mental processes—consciousness.. the Greek word for soul or mind. it aims to maintain old persons independently in the community as long as possible and to provide long-term care when needed. including criminology. ( f ) Cultural Psychiatry (Comparative Psychiatry): The branch of psychiatry concerned with the influence of the culture on the mental health of members of that culture. In Greek mythology. purposes of treatment and prevention. the term transcultural psychiatry is used. ideation. sensation.2
An Overview of Psychiatry
1. and ‘iatros’. The word Psychiatry is derived from ‘psyche’. 2. So is the psychiatry concerned with Adolescents— Adolescent Psychiatry. those below 12 years of age). the psychiatric role in compensation cases.e. Psychiatry: The medical speciality concerned with the study. of expert testimony. diagnosis.

both consciously and unconsciously as the style of life or way of being in adapting to the environment. Conation (psychomotor activity) and Affect (emotional part).4
Psychiatry for General Practitioners
3. Psychodynamics: The current usage of the term focuses on intrapsychic processes (rather than interpersonal relationships) and on the role of the unconscious motivation in human behaviour. memory. (It is divided into 3 components — Cognition (Intellect). for investigating mental processes by means of free association. Mind: It is the functional capacity of brain (brain is an anatomical structure. 5. A theory of psychology developed by Sigmund Freud out of his clinical experience with hysterical patients. rules and difficulties a sense of competition. particularly as such adjustment conforms to the community accepted standards of behaviour.g. the ingrained pattern of behaviour that each person evolves. 7. Personality: The characteristic way in which a person thinks. as in hobbies satisfaction with sexual identity ability to work under authority. 8. collaboration. 4. compromise. satisfaction and security ability to show friendliness and love ability to give and take tolerance of others and of frustrations and emotions ability to contribute a sense of humour a devotion beyond oneself ability to get along with others
. Psychoanalysis: A procedure devised by Sigmund Freud. Intelligence. dream interpretation.. feels and behaves. 6.) e. and interpretation of resistance and transference manifestations. Psyche: (Greek word meaning: ‘The Soul’) The mind. Mental Health: Psychological well-being or adequate adjustment. A form of treatment developed by Sigmund Freud that utilises for psychoanalytic procedure and is based on psychoanalytic psychology. Important characteristics of mental health are — — — — — — — — — — — — — — — — — — reasonable independence self-reliance self direction ability to do a job ability to take responsibility and make needed efforts reliability persistence ability to find recreation.

The healthy adult may at times have some minor psychiatric symptoms. while free of gross symptoms. Occupational Therapist: A graduate who is trained in observing and treating the patients through crafts and recreational activities. in Armed forces etc. in formulating “Mental Health Act”. Community mental health activities (e. Mental Health Programme etc. and usually feeling well..g. There are clinical implications of the concept of mental health i.An Overview of Psychiatry
5
— cooperation — optimism — ability to function in both dependent and independent roles. • Selection of treatment goals for psychiatric patients: Vocational screening e. are — marital problems — other interpersonal problems — phase of life problems — other specified family circumstances — academic problems — noncompliance with medical treatment. Psychiatric Nurse: A nurse who has received special training in the care and management of psychiatric patients. is not always happy. • Route examination of patients: Evaluation of patients who are apparently not mentally ill but who wish professional help with personal problems.) The problems not attributable to a mental disorder i. Psychotherapist: A person with special training in psychotherapy.e.
.g. Psychiatrist: A medical graduate who has successfully undergone a postgraduate training course (of 2 to 3 years) in psychiatry. A mentally healthy person. Psychiatric Social Worker: A graduate in sociology who has successfully undergone a postgraduate training course of 2 years in social case work. (Medical graduation is not a must). This consists of knowledge and experiences in investigations of the social and cultural milieu of the patients and methods of correcting it whenever it is pathogenic. diagnosis which may be used for persons without mental disease. Clinical Psychologist: A graduate in psychology who has successfully undergone a postgraduate training course (of 2 years) in clinical psychology.e..

Psychosomatic disorders (e. (The average prevalence of severe mental disorder is 2 per cent). Cannabis dependence etc. Drug abuse surveys have reported the prevalence rate ranging from about 2–40% (Alcohol. The other disorders such as Adjustment disorders.
. Psychosexual disorders are also not uncommon. 70–80). About 1–2% children suffer from learning and behaviour problems. Premature ejaculation. The common psychiatric illnesses encountered in a General Hospital Psychiatric Clinic are — Neuroses (Depressive neurosis followed by anxiety neurosis). Erectile impotence etc. In psychosexual clinics in India. Peptic ulcer. about 4 million severely mentally ill). malingering etc.5–1. enuresis. Among elderly (above 60 years of age) prevalence rate of mental morbidity is about 80– 90/1000 population of aged (i. cannabis and opium are common). about 3–5 times that number suffer from other forms of distressing and socio-economically incapacitating emotional disorders.e. Average number of new cases of serious mental disorders (Incidence) is about 35 per lac population. Polydrug abuse. borderline intellectual functioning (usually I. whereas in a Geriatric Clinic the common disorders are depression.6
Psychiatry for General Practitioners
Others—uncomplicated bereavement. anti-social behaviour. In India. 600–700 psychologists.). Magnitude of Problem in India Average prevalence of severe mental disorders is at least 18–20/1000 population. Manpower. Functional Psychoses (MDP depression. the common problems encountered include ‘Dhat syndrome’. Geriatric depression is most frequent with a prevalence rate of 60/1000. 300–400 psychiatric social workers and 700–800 psychiatric nurses.K. parent-child problems.. paranoid disorders etc.g. emotional and behavioural (conduct) problems. the patients who commonly come for treatment include Opiate dependence. Mental retardation estimated at 0. whereas in de-addiction clinics. This is in comparison to U. we have about 2500–3000 qualified psychiatrist. In a Child Guidance Clinic. Alcohol dependence. hyperkinetic syndrome etc. Hypertension. where the rate is as high as 260–265/1000. tobacco. mania and schizophrenia) and organic psychoses (usually delirium). the common mental illnesses include mental retardation.Q. dementia. 15–20% who visit general health services (such as a Medical OPD or a Private practitioner or a primary health centre) have emotional problems appearing as physical symptoms. Headaches etc.0% of all children. Tension.

3
Psychiatric Symptomatology. Interview and Examination
HISTORY TAKING — The patient and the attendants must be helped to feel comfortable enough to give a detailed account of psychiatric disorder. sex. occupation. course. marital status. age. reliability (i. ability. referral/direct. religion. to report.e. familiarity. Identification of patient. literacy. attitude towards patient. address. where seen (OPD/Ward). Identification of the patient * Name. intention for treatment) According to patient/ informant. onset.. relationship.
II. predisposing precipitating factors Nature of problem (Psychiatric and Physical) Date of onset Duration
Contd. history of physical/mental illness/drug abuse. Identification and reliability of informant
*
III. identification marks. reliability of information. Chief complaints or Reasons for referral and their duration IV.. A summary of history is given in Table 1. father’s name.
Table 1: Summary of Psychiatric History I. photo. length of stay with patient.. duration. History of present illness * Main problems (volunteered by patient and informants)
*
* * *
.

.g. Also other disturbances (e. Also history of substance abuse. Arrests. imprisonments. suicidal attempts.g. treatment. Attitudes to understanding of problems.. How they developed? When were they at their worst? Any changes since onset? And the factors or events responsible. appetite. Patient’s family’s and other helping resources and strength. sleep.
* Effects of the problem
* Treatment taken so far
* * * *
Nature and effects of psychological or physical treatment given Dose and duration of any psychotropic medication Compliance Time loss between onset of illness and treatment and reasons.
Contd.8
Psychiatry for General Practitioners
* * * Associated problems * * * Chronological development of problems * * * * * *
Severity Details as enlisted above. The factors increasing or decreasing severity. main complaints or diagnosis. Past History * Psychiatric history
* * * * * *
. compensation or psychological Dates.
* Patient’s understanding of the problem * Resources and strength * Legal issues * Secondary gain V. On — — — — — — — activities such as related personal hygiene work domestic tasks leisure activities social activities family and other relationships sexual activities. weight etc. Any complications e. suspension from job etc.) not narrated by the patient. Any gain.

Psychiatric Symptomatology, Interview and Examination

9

* *

Completeness of recovery and socialisation / personal care. History of drug abuse (types, duration, intoxication / withdrawal symptoms and treatment taken). Chronic medical illnesses (e.g. diabetes mellitus etc.) and details of medication. Any arrests, imprisonments, divorce, lawsuits etc. Types of family (Joint/Nuclear/Extended) Parental history (Ages or age of death, health, mental/physical), occupation, social position, personality and relationship with patient) Family dynamics (history of mental illness) Relationship among family members; family events (initiating or exacerbating illness). Birth Early development Educational history Occupational history Menstrual history Sexual history Marital history Religious history Legal record Personality traits Habits, hobbies, interests Beliefs, attitudes Social relationships Coping resources Alcohol drug abuse Any criminal record Is history reliable? Is it complete? Any need to contact other informants? Areas needing mental status examination.

MENTAL STATUS EXAMINATION
I. APPEARANCE AND BEHAVIOUR (a) Attitude Describe the manner in which the patient relates to the examiner i.e., — cooperative — friendly (Frank) — trustful — purposefulness — attentive — interested — seductive — hostile — contentious — playful — ingratiating — evasive — defensive — guarded Is it possible to emphathise? (“Empathy” is defined as the ability to identify with the patient in order to recognise and identify the mental state). Schizophrenic patients may be difficult to be empathised. Level of rapport (“Rapport” is a conscious feeling of accord, sympathy, trust and mutual responsiveness between one person and another). (b) General Appearance and Grooming — dressed with neatness — clothes appropriate to season — clothes clean and good — hair/nails — concern about appearance (c) Facial Expression — Is it appropriate or not? (Schizophrenic patients may have inappropriate or incongruous expression). — Does it change with subject or not? — Look—attentive, apathetic (e.g. in chronic schizophrenic), indifferent (e.g. in severely depressive). — Expression—elation, fears, anger, sad, blank. — Eye to Eye contact—avoids gaze, excessive scanning. (d) Posture — Relaxed, Guarded, Sitting at the edge of the chair or in a picture for prolonged period (e.g. in schizophrenic patients).

Psychiatric Symptomatology, Interview and Examination

11

(e) Gait and Carriage — Type of Gait—Normal, Brisk, Slow (e.g. in depressed patients), Desultory (e.g. in schizophrenic patients), Dilatory (e.g. in manic patients), Unsteady (e.g. in patients with organic brain disorders). (f ) Body Build — Asthenic (Leptosomatic or ectomorph) i.e., Persons with narrow in length with narrow, shallow thorax with narrow subcostal angle are believed to be more prone to schizophrenia. — Pyknic type (Endomorphic) i.e., Persons with large body cavities, relatively short limbs and large subcostal angle with rounded head and short, fat neck are believed to be more prone to manic depressive psychosis. — Athletic type (Mesomorphic) i.e., Persons with wide shoulders and narrow hips and well developed bones and muscles are believed to be more prone to drug dependence etc. (g) Psychomotor Activity — Appropriateness — Quantity: Normal, Increased (e.g. in mania, agitation), Decreased (e.g. in severe depression). — Quality: Facial movements e.g. in oral dyskinesia, tremors in hands or body. — Mannerisms i.e., odd, repetitive movements, may be a part of a goal directed activity (e.g. in normal persons, maniacs). — Stereotypies i.e., Motor or verbal repetition without any discernible goal e.g. in schizophrenics. — Automatic obedience (a type of catatonic behaviour when verbal instructions are overridden by tactile or visual stimuli e.g. the patient shakes hands with the examiner contrary to the firm verbal instructions whenever the examiner’s right hand is extended) e.g. in schizophrenic patients. — Mitmachen (Despite instructions to the contrary, the patient will allow a body part to be put into any position without resistance to the light pressure). — Echopraxia e.g. in Catatonic Schizophrenics (Automatic copying of the examiner’s movements or postures). — Echolalia (Automatic repetition of the examiner’s utterances) e.g. in catatonic schizophrenic patients. — Catalepsy (Prolonged sustaining of an awkward posture or position) e.g. schizophrenic patients. (c.f. cataplexy, a type of sleep disorder). — Cerea flexibilitas or waxy flexibility. (If the examiners encounter plastic resistance like the bending of a wax rod when moving the patient’s arm, which will then be maintained in an odd position) e.g. in Catatonic Schizophrenic. — Cogwheel or Lead pipe rigidity (e.g. in parkinsonism). — Compulsions—are obsessional motor acts (e.g. in obsessive compulsive disorder).

Functional hallucinations: Occur only when there is a concurrent real perception in the same sensory modality (e.e. — Derealisation: It involves a similar alteration in the sense of reality of the outside world.g. Expanded e.g. hearing voices only when the water tap is on). in depression. Anxious (e. Fear (e. in mania. auditory. Blunting (affects are diminished in intensity and constricted to a narrow neutral range) e. (c) Depersonalisation and Derealisation These are alternations in the perception of one’s reality.g.g. Liability e.g. Kinaesthetic hallucinations: Feeling movement when none occurs e. in schizophrenia.g. Illusion may occur in normal individuals or in organic mental disorders. Extracampine hallucinations: When occurring outside of a known sensory field (e. — Deja entendu: The feeling that one had at some prior time heard or perceived what one is hearing in the present. Hypnopompic hallucinations: which occur when awakening.g. (b) Hallucinations Perceptions occurring without external stimulation.14
Psychiatry for General Practitioners
— Type: Elated (e.g. in phobia). visual.g. — Jamais vu: An erroneous feeling or conviction that one has never seen anything like that before (i. in mania). Feeling of unfamiliarity). PERCEPTION (a) Illusions These are misinterpretations of perceptions (e.g. verging on certainty that he has already thought of the matter. Hypnagogic hallucinations: which occur when falling asleep. — Deja pense: A patient’s feeling. Irritable (e. in organic mental disorders. gustatory.g. in hypomania). III. — Stability: Stable. olfactory. shadows are mistaken for frightening figures). Flat (No affective response at all) e.g. Anger (e. (It is an “as if” phenomenon and patient is not fully convinced). Hallucinations may depend on type of sensory system affected e. in schizophrenia). in anxiety neurosis).g. — Depersonalisation: The patient feels detached and views himself or herself as strange and unreal. (Familiar objects or places may seem altered in size and shape). in schizophrenia. out of body experiences. Sad (e.g.. (d) Other Abnormal Perceptions — Deja vu: Feeling of familiarity with unfamiliar things.g. in depression).
. — Range: Constricted e.g. Autoscopic hallucinations: A visual hallucination of patients themselves. seeing objects through a solid wall).

accompanied by a lack of awareness on the part of the patient that ideas are not connected. repetition of the same words or phrases over and over again despite the interviewer’s direction to stop. irrational fear about a real or an imaginary object. e. — Tangentiality: It differs from circumstantiality that the final goal is not reached and the patient loses track of the original question.Psychiatric Symptomatology. place or a situation. like a parrot. e. Interview and Examination
15
IV. e.g. king. king. thoughts. THINKING (a) Stream It includes (i) Disorders of Tempo — Flight of ideas (Rapid speech with quick changes of ideas) that may be associated by chance factors such as by the sound of the words but which can usually be understood. in mania. impulses or phobias. sing. organic mental disorders. — Echolalia: Repetition of the interviewer’s words.g.g. Primary delusions can be:
. in mania. wing wing). — Phobias: Persistent. (b) Possession and Control — Obsessions: Persistent occurrence of ideas. withdrawal or broadcasting. It may be insertion. excessive. and they cannot be explained on the basis of reality. (See the king is standing. bird on the wing. sing. — Inhibition or retardation — Circumstantiality: Thinking proceeding slowly with many unnecessary trivial details but finally the goal is reached e. It occurs in schizophrenia and anxiety states. The patients lack insight into it. — Blocking: Occurs when the thinking process stops altogether.g. — Suicidal/homicidal thoughts. (c) Content (i) Primary Delusions Fixed unshakable false beliefs. — Incoherence: Marked degree of loosening of associations in which the patient shifts ideas from one to another with no logical connection. — Thought alienation: The patient has the experience that his thoughts are under the control of an outside agency or that others are participating in his thinking. schizophrenia. (ii) Disorders of Continuity — Perseveration: Mental operations tend to persist beyond the point at which they are relevant. which are against one’s sociocultural and educational background. It is seen in schizophrenia. images. The patients may or may not start with the same topic again.

(ii) Given by Goldstein In schizophrenia and organic mental disorders.
. his mind or the world around). It cannot be understood from one’s affective states or previous attitudes. for a pen-writing stick).g. ill health or somatic function. self-reference. the patient unconsciously thinks ‘I love him—I do not love him—I hate him—he hates me.e.’ (iii) Content of Delusions Delusions of: persecution.g. — Delusional perception: Attribution of a new meaning usually in the sense of selfreference. love or erotomania. to a normal perceived object. there is a loss of abstract form i. thinking becomes concrete (patient is unable to free himself from the superficial concrete aspects of thinking). — Metonyms: Imprecise expressions or use of substitute term or phrase instead of more exact one (e. guilt.g. (ii) Secondary Delusions They arise from some other morbid experience. (iii) Given by Schneider (Mnemonic ‘FODDS’) — Substitution (A major thought is replaced by a subsidiary one). — Desultory thinking (speech in grammatically and syntactically correct but sudden ideas force their way from time to time). the king saluted him. — Omission (senseless omission of a thought or part of it). e. — Drivelling (Disorganised intermixture of constituent parts of one complete thought).16
Psychiatry for General Practitioners
— Delusional mood: Patient thinks that something is going on around him which concerns him but he does not know what it is. poverty. a patient says that he of royal descent because he remembers when he was taken to a military parade as a little boy. — Sudden delusional ideas: A sudden revelation or well-formed ideas appear in the thinking e. — Fusion (Heterogeneous elements of thoughts are interwoven). nihilism (the patient denies the existence of his body.g. — Interpenetration of themes: The patient’s schizophrenic’s speech contains elements which belong to the task in hand interspersed with a stream of phantasy which he cannot understand. For example. (d) Form of Thinking (i) Given by Cameron — Asyndesis: Lack of adequate connections between successive thoughts.. — Overinclusion: Inability to maintain the boundaries of the problem and to restrict operations within their correct limits. e. grandiosity. patient hears the stairs creak and knows that this is a detective spying on him. The patient shifts from one hypothesis to another. delusions.

Psychiatric Symptomatology, Interview and Examination

17

V. JUDGEMENT It is the capacity to draw direct conclusions from the material acquired by experience. It is impaired in psychoses. — Test judgement (Patient’s prediction of what he or she would do in imaginary situations). — Social judgement (Subtle manifestations of behaviour that are harmful to the patient and contrary to acceptable behaviour in the culture). VI. INSIGHT It refers to subjective awareness of the pathological nature of psychiatric symptoms and behavioural disturbances. Lack of insight is characteristic of psychoses. Clinical Rating of Insight Insight is rated on a 6-point scale from one to six. 1. Complete denial of illness. 2. Slight awareness of being sick and needing help, but denying it at the same time. 3. Awareness of being sick, but it is attributed to external or physical factors. 4. Awareness of being sick, due to something unknown in self. 5. Intellectual insight: Awareness of being ill and that the symptoms/failures in social adjustment are due to own particular irrational feelings/thoughts; yet does not apply this knowledge to the current/future experiences. 6. True emotional insight: It is different from intellectual insight in that the awareness leads to significant basic changes in the future behaviour and personality. VII. SENSORIUM AND COGNITION (a) Consciousness Awareness of facts and the content to mental phenomenon and degree of reactivity of the environment. Consciousness may be clouded e.g. in organic mental disorder. (b) Orientation Awareness about time, place and person. When it is impaired, it is usually in the order of time, then place and then person and when it is regained it is in the reverse order. (c) Attention and Concentration — Active attention (concentration): The amount of effort the patient exerts to solve a problem. It is tested by asking the patient to solve certain problems. (e.g. keep on subtracting seven from 100 or 4 times 5 or months of the year backwards). — Passive attention: The attention, which the environment draws, and the patient pays very little effort e.g. a shop on fire, an accident.

18

Psychiatry for General Practitioners

(d) Memory The ability, process or act of remembering of recalling and especially the ability to reproduce what has been learned or experienced. The memory can be: — Remote memory: The ability to recall information what was experienced in the distant past. — Recent past memory: The past few months. — Recent memory: The past few days, recall of what was done yesterday, the day before, what was eaten for breakfast, lunch, dinner etc. — Immediate retention and recall: The ability to register information. Ability to repeat 5–6 figures after examiner dictates them—first forward and then backward, then after a few minutes interruption. The memory may be impaired in organic mental disorders (dementia) or amnesia (organic and psychogenic). (e) Abstraction (Abstract Thinking) It is determined by asking the meaning of common (prevalent in a culture) idioms, proverbs and similarities and differences between objects in the same class, e.g. similarities and differences between “ball and orange” “fly and aeroplane” etc. (f) General Intelligence It can be gauged by patient’s vocabularies, complexity of concepts they use and progressively more difficult questions about current events. (g) Attitudes and Beliefs It is important to note patient’s attitudes and beliefs towards — the illness — the consequences of and limitations imposed by the illness. — any help offered.

dementia or psychopathic personality. Concreteness in proverb interpretation suggests an impairment of abstraction. Psychological treatments may attempt either to reduce the symptoms of the phobia or to resolve the underlying anxiety. Agoraphobia: Fear of open places: as phobic disorder characterised by a fear of leaving one’s home. anxiety. Affect. pacing. appropriate. thought or speech accompanying it. It is the commonest form of phobia. inability to sit still. Affect: The subjective and immediate experience of emotion attached to ideas of mental representations of objects. blunted. Affect. Restricted: Affective expression characterised by a reduction in its range and intensity. occurring characteristically in schizophrenia of the hebephrenic type but also in organic cerebral disorders. Agnosia: Inability to understand the importance of significance of sensory stimuli cannot be explained by a defect in sensory pathways or sensorium. writhing of hands or pulling of clothes. Aggression: Forceful physical. Affect. Agraphia: Loss of impairment of a previously possessed ability to write. It may present with or without panic attacks. Affect. Affect.
. seen in clinical practice. Inappropriate: Emotional tone that is out of harmony with the idea. flattened. fidgeting. It is one of that disorder’s fundamental symptoms. Affect has outward manifestations that may be classified as restricted. verbal or symbolic action. This may occur in schizophrenia. Agitation: Excessive motor activity. or inappropriate. elation. Affect. as outlined by Eugen Bleuler. Observed in schizophrenia. most frequently seen in organic brain syndromes. Flat: Absence or near absence of any signs of affective expression. Blunted: A disturbance of affect manifested by a severe reduction in the intensity of externalised feeling tone. Abnormal: A general term describing morbid or unusual mood states of which the most common are depression. May be appropriate and selfprotective. may follow parietal lobe damage. Interview and Examination
21
GLOSSARY
Abstraction: The process whereby thoughts or ideas are generalised and dissociated from particular concrete instances or material objects. irritability and affective lability. usually non-purposeful and associated with internal tension. mental retardation and personality disorders. Shallow: A state of morbid sufficiency of emotional response presenting as an indifference to external events and situations. Affect. Labile: Affective expression characterised by repetitious and abrupt shifts. Examples. as in schizophrenia. including healthy self-assertiveness or inappropriate as in hostile or destructive behaviour. early schizophrenia and some forms of personality disorders.Psychiatric Symptomatology.

The inability cannot be explained by paralysis or sensory impairment. emotional or of mixed origin and limited to a sharply circumscribed period of time. Anxiety: Unpleasurable emotional estate associated with psychophysiological changes in response to an intrapsychic conflict. Attention: Concentration. Aypnia: Insomnia. a feature of command automatism associated with catatonic syndromes and the hypnotic state. knowledge. It may be organic. as in the extreme immobility of catatonic schizophrenia. In neurology. Amnesia: Pathologic loss of memory. Ataxia: Lack of coordination. leading to contradictory behaviour. It is a symptom observed in severe cases of catatonic schizophrenia. Automatism: Automatic and apparently undirected non-purposive behaviour that is not consciously controlled.
. Apperception: Awareness of the meaning and significance of a particular sensory stimulus as modified by one’s own experiences. cognisant of information received from the immediate environment. most frequently seen in catatonic schizophrenia. the aspect of consciousness that relates to the amount of effort exerted in focussing on certain aspects of an experience. Seen in the psychomotor epilepsy. Automatic obedience: The phenomenon of undue compliance with instruction. it refers to loss of muscular coordination. See also perception. Apraxia: Inability to perform a voluntary purposeful motor activity. inability to sleep. thoughts and emotions. anterograde: Inability to form new memories following such condition(s). activity or task. See also Command automatism. Catalepsy: Condition in which a person maintains the body position which he is placed. Ambitendence: A psychomotor disturbance characterised by an ambivalence towards a voluntary action. Aphasia: A disturbance in language function due to organic brain disorder. In psychiatry. Akinesia: Lack of physical movement.22
Psychiatry for General Practitioners
Akathisia: A state of motor (or less often verbal) restlessness manifested by the compelling need to be in constant movement. Attitude: A ‘mental set’ held by an individual which affects the ways that person responds to events and organises his cognitions. It is observed in certain types of schizophrenia and depression. the danger or threat in anxiety is unreal. a phenomenon in which an area of experience becomes inaccessible to conscious recall. the disturbance is found in schizophrenia. either physical or mental. Apathy: Want of feeling or affect or interest or emotional involvement in one’s surroundings. It may be seen as an extrapyramidal side effect of butyrophenone or phenothiazine medication. Awareness: A subjective state of being alert or conscious. Two types are: retrograde: Loss of memory for events preceding the amnesia proper and the condition(s) presumed to be responsible for it. in contrast to fear. It is also known as waxy flexibility and cerea flexibilitas. the term ‘intrapsychic ataxia’ refers to lack of coordination between feelings and thoughts.

Psychiatric Symptomatology. It is observed in schizophrenia. rather than its meaning. apathy. Also known as clanging. See also Abstract thinking. Groups that study their own processes and dynamics use more cognition than the encounter groups. rather than by abstractions. slowness of mental processes with scanty association of ideas. Confabulation: Unconscious filling the gaps in memory by imaging experiences or events that have no basis in fact. and it is often followed by sleep. Confusion: A term usually employed to designate a state of impaired consciousness associated with acute or chronic cerebral organic disease. external (environmental) or internal demands. Conflict: A mental struggle that arises from the simultaneous operation of opposing impulses. Concrete thinking is seen in young children: in those who have lost or never developed the ability to generalise as in certain organic mental disorders. obsessional disturbances. Conation: That part of person’s mental life concerned with his strivings. and failure to perform the act leads of to overt anxiety. Termed intrapsychic when the conflict is between forces within the personality. See also Tangentiality. Clang association: Association or speech directed by the sound of a word. Compulsion: Uncontrollable.
. fatigue and poor attention. drives. drives and wishes as expressed through his behaviour. It serves as a defense against unacceptable ideas and desires. Confabulation should be differentiated from lying. Catathymia: A situation in which elements in the unconscious are sufficiently affected to produce changes in conscious functioning. Cognition: Mental process of knowing and becoming aware. motivations. Concrete thinking: Thinking characterised by actual things and events and immediate experience. It is common in organic amnestic syndromes. It can be precipitated by a variety of emotional states. Cerea flexibilitas: The waxy flexibility often present in catatonic schizophrenia in which the patient’s arm or leg remains in the position in which it is placed. Interview and Examination
23
Cataplexy: Temporary sudden loss of muscle tone. See also Obsession. and in schizophrenics. One of the ego functions. Repetition compulsion. and certain cases of dementia. Punning and rhyming may dominate the person’s verbal behaviour. lack of initiative. See also Paramnesia. extrapsychic. It is closely associated with judgement. Circumstantiality: Disturbance in the associative thought and speech processes in which the patient digresses into unnecessary details and inappropriate thoughts before communicating the central idea. repetitive and unwanted urge to perform the act. causing weakness and immobilisation. which emphasise emotions. when it is between the self and the environment. It is seen most frequently in schizophrenia or mania. Command automatism: Condition closely associated with catalepsy in which suggestions are followed automatically. It is also known as thinking. Clinically it is characterised by disorientation.

Encapsulated delusion. practices. Delusion that a person’s thoughts. reversible organic mental disorder characterised by confusion and some impairment of consciousness. distractibility. Deja pense: A condition in which a thought never entertained before is incorrectly regarded as a repetition of a previous thought. difficulty with calculations. give symbolic external expression. Poorly elaborated delusion. despite objective and obvious contradictory proof or evidence and despite the fact that other members of the culture do not share the belief. Depressive delusion that the world and everything related to it have ceased to exist. attitudes or ideas.24
Psychiatry for General Practitioners
Congruence: A general term used to refer to behaviour.
. Somatic delusion. Exaggerated concept of one’s importance. Conscience: The morally self-critical part of one’s standards of behaviour. Delusion of jealousy (delusion of infidelity). Delusion without significant effect on behaviour. A group of elaborate delusions related to a single event or theme. appearances. Nihilistic delusion (delusion of negation). or ideas. Religious delusion. performance and value judgements. Delusion pertaining to the functioning of one’s body. reduced facility with language. Deja vu: Illusion of visual recognition in which a new situation incorrectly regarded as a repetition of a previous experience. Delirium: An acute. Constitution: A person’s intrinsic psychological or physical endowment. often one of many with no apparent interconnection. Sexual delusion. Delusion of reference. or actions are not his own but are being imposed on him by some external force. Delusion that one is or will be without material possessions. attitudes or ideas which are in accord and not in conflict with other such behaviour. Delusion of persecution. Delusion of persecution grandiose delusion. Conversion: A defense mechanism. Delusion of grandeur (grandiose delusion). Delusion that events. Paranoid delusion. Commonly equated with the superego. Delusion that one’s lover is unfaithful. and disturbance of orientation. impairment in judgement and abstraction. Coprolalia: The use of vulgar or obscene language. Delusion of control. Dementia: An organic mental disorder characterised by general impairment in intellectual functioning. knowledge. or the state of having this awareness. or the behaviour of others have a particular and unusual meaning specifically for oneself. Frequent components of the clinical syndrome are failing memory. Systemised delusion. Delusion involving the Deity or theological themes. Delusion centering on sexual identity. False belief that is patiently absurd or fantastic. Consciousness: The awareness of one’s own mental processes. Deja entendu: Illusion that what one is hearing one has heard previously. See also (Paramnesia). operating unconsciously. alterations in mood and affect. objects. Fragmentary delusion. feelings. Types of delusion include Bizarre delusion. by which intrapsychic conflicts that would otherwise give rise to anxiety are. instead. or identity. power. Delusion: A false belief that is firmly held.

Echolalia: Repetition of another person’s words or phrase. Schizophrenia. parts of oneself. When severe. It is important ability in a successful therapist or a helpful group member. Derealisation: Sensation of changed reality or that one’s surroundings have altered. See also Depersonalisation. Dissociation: The splitting off of clusters of mental contents from conscious awareness. and self-approach. Extroversion: The state of one’s energies being directed outside oneself. Flight of ideas is most frequently seen in Manic episodes. Dystonia: Extrapyramidal motor disturbance consisting of slow. and schizotypal personality disorder.Psychiatric Symptomatology. It is usually seen in schizophrenics. It is observed in some cases of schizophrenia. sustained contractions of the axial or appendicular musculature. and vegetative symptoms. Depression: A mental state characterised by feeling of sadness. the separation of an idea from its emotional significance and affect as seen in the inappropriate affect of schizophrenic patients. It is also spelled as extraversion. a mechanism central to hysterical conversion and dissociative disorders. usually based on understandable associations. It involves the projection of oneself into another person’s frame of reference. such as insomnia and anorexia. withdrawal from interpersonal contact. Acute dystonic reactions (facial grimacing. one movement often predominates.
. See also Ego boundaries. or one’s environment which occurs under extreme stress or fatigue. and occasionally. loneliness. or plays on words. Interview and Examination
25
Depersonalisation: Sensation of unreality concerning oneself. despair. torticollis) are occasionally seen with the initiation of antipsychotic drug therapy. It is seen in schizophrenia. particularly the catatonic types. Gilles de la Tourette’s disease. Observed in certain cases of schizophrenia. See also Sympathy. See also Communication disorder. The behaviour is considered by some authors to be an attempt by the patient to maintain a continuity of thought processes. low selfesteem. but may also be observed in some cases of Organic Mental Disorders. Empathy: The intellectual and emotional awareness and understanding of another person’s state of mind. Doctor-patient relationship: Human interchange that exists between the person who is sick and the person who is selected because of training and experience to heal. leading to relatively sustained postural deviations. other psychotic disorders. Echopraxia: Repetition of another person’s movements. distracting stimuli. depersonalisation disorder. Emotion: The experience of subjective feelings which have positive or negative value for the individual. Flight of ideas: A nearly continuous flow of accelerated speech with abrupt changes from topic to topic. acute reactions to stress. Accompanying signs include psychomotor retardation or at times agitation. the speech may be disorganised and incoherent. parts of oneself.

Formal thought disorder: A disturbance in the form of thought as distinguished from the content of thought. Visual hallucination. Kinaesthetic hallucination. Olfactory hallucination. excessive use of incomplete sentences’ excessive irrelevancies or abrupt changes in subject matter. theories of forgetting can be sorted into seven major approaches. for the most part. usually at bedclothes or clothing. idiosyncratic word usage. and other psychotic disorders. Visual sensation that persons or objects are reduced in size. Examples include: Auditory hallucination. Somatic hallucination. Illusion: Perceptual misinterpretation of a real external stimulus. distorted grammar. Hallucination involving the sense of touch. Hallucination involving smell. Gastatory hallucination. interference theory. Forgetting: Broadly speaking. Incoherence: Speech that. It is common in senile psychosis and delirium. It is highly important in effecting changes in the personality and behaviour of a person. Hypnagogic hallucination. Hallucination occurring while awaking for sleep (ordinarily not considered pathological). “formal thought disorder” is not used as a specific descriptive term in DSM-IV. For this reason. Mildly ungrammatical construction or idiomatic usages characteristic of particular regional or ethnic backgrounds. lack of the relevant context of retrieval. Schizophrenia. It is most commonly encountered in cocainism and delirium tremens. Intellectual insight refers to knowledge of the
.26
Psychiatry for General Practitioners
Floccillation: Aimless plucking or picking. motivated forgetting. and inadequate processing during storage. Hallucination of bodily movement. Tactile (haptic) hallucination. Hallucination of taste. Hallucination involving sight. In psychiatry. Lilliputian hallucination. unless strengthened by being retrieved). decay theory (the idea that memory traces gradually decay overtime. phrases. is not understandable. Hallucination involving the perception of a physical experience localised within the body. Formication: A tactile hallucination involving the sensation that tiny insects are crawling over the skin. Insight: Conscious recognition of one’s own condition. The boundaries of the concept are not clear and there is no consensus as to which disturbances in speech or thoughts are included in the concept. it is more properly regarded as an illusion (see also Micropsia). lack of education. and the term is generally not applied when there is evidence that the disturbance in speech is due to an aphasia. lack of appropriate cues for retrieval. or low intelligence should not be considered coherence. it more specifically refers to the conscious awareness and understanding of one’s own psychodynamics and symptoms of maladaptive behaviour. Hallucination of sound. or sentences. Hallucination: A false sensory perception occurring in the absence of any relevant external stimulation of the sensory modality involved. Idea: The memory of past perceptions. owing to any of the following: a lack of logical or meaningful connection between words. Incoherence may be seen in some Organic Mental Disorders. amnesia brought about through physical causes. An idea depends upon an image in the same way as a perception depending upon a sensation.

for example. Definitions restrict the use of the term to those new words or phrases whose derivation cannot be understood. Literally “beautiful indifference. See also Paramnesia.
.” Loosening of associations: A characteristic schizophrenic thinking or speech disturbance involving a disorder in the logical progression of thoughts. It is seen in patients with conversion disorder.Psychiatric Symptomatology. “headshoe” to mean “hat. reflective life-style. See also Metonymy. Word approximation. Mental disorder: A psychiatric illness or disease. Are manifestations primarily behavioural or psychological? It is measured in terms of deviation from some normative concept. Mood: A pervasive and sustained emotion that in the extreme. it is a paramnestic phenomenon. Mood-incongruent psychotic features: A DSM-II term which refers to hallucinatory or delusional phenomena whose content consistently reflect the mood of a manic or depressed patient. and apply what one has learned. Mental retardation: A condition of arrested or incomplete development of the mind which is especially characterised by subnormality of intelligence. However. common examples of mood include depression. Introvert: An individual inclined towards a solitary. Interview and Examination
27
reality of a situation without the ability to successfully use that knowledge to effect an adaptive change in behaviour. Emotional insight refers to deeper level of understanding or awareness that is more likely to lead to positive change in personality and behaviour. Mood is to affect as climate is to weather. It is commonly seen in catatonic schizophrenia in which the patient resists any effort to be moved or does the opposite of what is asked. anger and anxiety. markedly colours the person’s perception of the world. Neologism: New word or phrase. Intelligence: The capacity for learning and the ability to recall. La belle indifference: An inappropriate attitude of calm or lack of concern about one’s disability. See also Hysterical neurosis. It may also occur in organic psychoses an mental retardation.” Those words are more properly referred to as word approximations. Unrelated and unconnected ideas shift from one subject to another. manifested as a failure to adequately verbally communicate. the capacity to understand and to think rationally. Mood-congruent psychotic features: A DSM-III term which refers to hallucinatory or delusional phenomena whose content consistently reflects the mood of a manic or depressed patient. often seen in schizophrenia. elation. See also Nihilism. the term “neologism” has also used to mean a word that has been incorrectly constructed but whose origins are nonetheless understandable. Jamais vu: False feeling of unfamiliarity with a real situation that one has experienced. Negativism: Verbal or nonverbal opposition or resistance to outside suggestions and advice. integrate constructively. Paraphysis.

Perplexity: A state of puzzled bewilderment in which verbal responses are desultory and disjointed. or even irrelevant manner and the central idea is not communicated. See also Apperception. A good therapeutic alliance is especially necessary for the contribution of treatment during phases of strong negative transference. but in DSM-III it refers only to answers to questions and not to spontaneous speech. digressive. thought. essentially incomprehensible mixture of words and phrases commonly seen in far-advanced cases of schizophrenia. and mutual responsiveness between two or more persons. See also Countertransference. loud. in which the goal idea is reached in a delayed or indirect manner. Paraphasia: Type of abnormal speech in which one word is substituted for another. Failure to communicate the central idea distinguishes tangentially from circumstantiality. See also Working alliance. See also Incoherence.28
Psychiatry for General Practitioners
Obsession: Persistent and recurrent idea. Tangentiality: A disturbance in which the person replies to a question in an oblique. as well as sensory—are organised meaningfully. Word salad: An incoherent. See also Communication disorder. accelerated speech. Obsessions are involuntary and egodystonic. severe anxiety. reminiscent of confusion. Resistance is linked to underlying psychological defense mechanisms against impulses from the id that are threatening to the ego. meaning. Rapport contributes to an effective therapeutic process in both group and individual settings. Logorrhea. It involves a therapeutic splitting of the patient’s ego into observing and experiencing parts. schizophrenia. Transference. Stupor: State of decreased reactivity to stimuli and less than full awareness of one’s surroundings. Rapport: Conscious feeling of harmonious accord.
. manic-depressive illness and the organic psychoses with confusion. the irrelevant word generally resembles the required one in its morphology. rapid. Phenomenology: The study of events or happenings in their own right. Therapeutic alliance: Conscious contractual relationship between therapist and patient in which each implicitly agrees that they need to work together to help the patient with his problems. It is also called pressured speech. See also Compulsion. and organic disorders. Perception: The conscious awareness of elements in the environment by the mental processing of sensory stimuli. or impulse that cannot be eliminated from consciousness by logic or reasoning. or phonetic composition. The term has been used roughly synonymously with loosening of associations and speech derailment. Its clinical associations include acute schizophrenia. Occurs in mania. Pressure of speech: An increase in the amount of spontaneous speech. rather than from the point of view of inferred causes. Resistance: A conscious or unconscious opposition to the uncovering of unconscious material. The term is sometimes used in a broader sense to refer to the mental process by which all kinds of data—intellectual and emotional. sympathy.

” In India. Its chief features are various types of delusions which occupy the sufferer’s mind but do not disable him in daily life to the same extent as schizophrenia does. perceiving and behaving. Hence. Relatives liken schizophrenia to living death. Delusional disorder is rarer than schizophrenia but commoner than Brief Psychotic Disorder. Brief Psychotic Disorder and Delusional Disorder
Psychotic disorders are serious mental illnesses in which the ability to recognise and respond rationally to reality. three to four people in 10. the degree of social and occupational disability is much less. aptly also called “cancer of the mind. Our ancients knew schizophrenia well. disorders primarily of thought and behaviour and those with primary disturbance of mood. perception and behaviour. is lost. This is a grave injustice to the enormity of the problem.4
Psychoses: Schizophrenia. and to the profound suffering associated with this disease. One can therefore. These disorders will not be discussed further here. schizophrenia is the most common. This chapter is a brief description of psychotic disorders primarily of disturbance of thought. Schizophrenia Every day we read the term “schizophrenic” used in all contexts. Delusional disorder is one of “Schizophrenia Spectrum” disorders which means that it segregates in the same families as schizophrenia. these numbers are also increasing. Brief psychotic disorder is rarer forms of the disease and will not be described further here. The Ayurveda called it unmada and
. With increasing life span. Psychotic disorders are commonly divided into three main groups—those of organic origin (where etiology is recognised to be due to an identifiable physical cause). estimate that there are approximately at least two million people suffering from schizophrenia in India at any point of time.000 fall ill with schizophrenia every year. Nearly 40–60% of such sufferers end up significantly disabled. Of the three disorders in the title. In clinical practice this manifests as odd or unusual thinking. In addition. over four lakh cases are added to this number every year.

However there is said to be a greater incidence in men than women. because affected persons often leave home and migrate to urban areas. Shakuntala gradually stopped eating altogether and lay in bed. a pavement seller. calling Shri Krishna her child and refusing to eat any food except what she herself offered as prasad. Some Case Histories Case 1 Shakuntala. of the rich or the poor. while delusional disorders account for a fractional percentage of the general population. creed or community. It usually begins in adolescence just when the person is learning to be independent and to deal with the world. and with similar symptoms and course. she attributed it to Krishna writing his name on the table. It was only when Shakuntala stopped bathing or changing her clothes and began to mutter to herself that the family knew that something was wrong. and in urban areas. Only the fortunate few get one episode and then recover partially or fully. and increased risk for suicidal and assaulting behaviour (10% of patients commit suicide).30
Psychiatry for General Practitioners
described treatments for it— Rauwolfia serpentina or Sarpagandha. believed a Khan—a movie star—was out to kill him. This could also be due to social drift. She believed that Krishna slept with her. a drug still being used in modern medicine. and incidence and life time prevalence are roughly equal worldwide. Schizophrenia is an illness present in Indian society as well as all other societies down the ages. a minority never recovers from the first episode. Case 3 Roshni believed her sons are not really her own but were planted on her during her delivery (possibly by the doctor. It is not a disease of any particular caste. It is found in all societies and geographical areas. She cannot explain the origin of her belief
. while disorders related to it (“Schizophrenia spectrum” disorders) are approximately 5%. in fact. so there was no question of any physical relationship with her husband. perhaps because of increased risk of substance abuse in West. When the glass top of a table placed near her cracked in winter. suddenly became a very religious person. and then disappearing with the glass. taken cold and only once a day. the whole country was against him because he knew secrets against powerful people. The majority of sufferers —men or women of any age group —continue to get episodes of illness. and brought her for treatment. The course of Schizophrenia has been documented to be more severe in developed countries and the outcome better in developing and more rural societies. in her twenties. Case 2 Samir. Epidemiology Schizophrenia occurs all over the world. Its prevalence rate is just below 1%. or possibly by her husband).

She told her mother that when she was ten. and put obstructions in his way. which meant he had put his sperms into her body. her father had exchanged his daal bowl for hers. In addition to medication. His brother Suresh Chand fell ill at age 38. She had to be withdrawn from school both because of her odd behaviour and also because of her repeated failures. The scars of schizophrenia will always remain on Neetu’s psyche and she will never really be socially comfortable. and is now thinking of joining Open School to complete her 12th. She became restless and inattentive in class. hardly speaking to anyone at home. at the age of 24. is doing poorly at his job and finds it difficult to meet daily requirements of life. her personality gradually began to change. He began to feel that whenever he spoke to someone. that the listener could not understand it. Their sister Parvati was luckier. his own brain would be uncovered and the other person could immediately understand what he was going to talk about. she started keeping herself as far away as possible from her father. He complains that whenever he speaks. and her behaviour became more and more queer. Five years before her illness began. One terrible day. These spirits control his body. the disease may affect many members. her parents heard of a new antipsychotic drug and consulted another psychiatrist. sociable. She became a recluse. Brief Psychotic Disorder and Delusional Disorder
31
nor why anyone should substitute her children. which unfortunately did not suit Neetu. Case 5 In a family. the “truth” came out. He became very religious. They pollute his thoughts. Then later
. Finally. Here is an example. decades after the first onset. Even more worrying to her parents. with help from her husband and in-laws! Case 4 Neetu was a carefree. fifteen year old. he often complains of numerous bodily symptoms. accepting that her delusions about him were not real. She refused to take medicines. mind and his thoughts even today. Now. He consults psychiatrists intermittently. No illness (except schizophrenia) has ever been diagnosed. when she was 22. She now often laughed without reason. This outlandish statement alarmed her mother and a psychiatrist was consulted. he involuntarily switches on to a totally different topic and his brain is totally empty. The first to fall ill was Laxmi Chand. She cooks for her family once in a while. after her husband’s death when she was 51. and sometimes would cry without reason too. moody. She fell ill relatively late. When she was in the tenth standard. He prescribed antipsychotic drugs. silent and withdrawn at home. This went on for years. This does not prevent her from looking after her children fairly competently. often not even bathing for days together. She had realised this truth only now.Psychoses: Schizophrenia. But Neetu is now friendlier with her father. He isolated himself from his relatives because he believed that they had set evil spirits onto him. and spent all his time praying to try and drive away the evil spirits troubling him. loving. As a result he has become a total recluse. rehabilitation and psychotherapy were also begun. doing academically well in her private school. His speech became so disorganised even abusive. He felt he could no longer control his emotions. she became reclusive and isolated.

and warned her that if she allowed anyone in her family to go out of the house the voices would kill them. someone was following her and was convinced all fruit sellers. commenting on her. Etiology Schizophrenia has a very strong hereditary component. she would not allow her children to go out at all. cognitive dysfunction and disturbances in affect. A famous movie star—xxx Khan though. and “gave” her strange tastes and smells. She felt fearful. despite strong evidence for genetic susceptibility. Thus schizophrenia may be due to failure of the normal development of the brain or a disease process that alters a normally developed brain leading to multiple possible outcome types. and heard shrill voices. monozygotic and dizygotic. one or more specific gene/s has not been unambiguously identified so far. Shakuntala. rhesus (Rh) factor incompatibility may all end into the schizophrenia phenotype. A given susceptibility gene may or may not result in the disorder. She felt some ghosts were using her body and spoiling her. then schizophrenia should be considered. But even monozygotic twins are not always concordant (i. Neetu and Roshni are all suffering from schizophrenia. Alternately genetic susceptibility or “mistakes” in neurodevelopment during intrauterine life may also increase susceptibility to this disorder. Samir. she began to feel that many people were speaking inside her. This may be due. Remission is full • With/without marked stressors • Emotional turmoil and confusion: good prognosis • Negative symptoms: poor prognostic features • Confusion or perplexity at the onset. Apart from the dramatic symptoms outlined above.“proband” . subtle neurological manifestations.
. Environmental factors such as gestational and birth complications. Brief Psychotic Disorder • ICD-10: psychotic conditions with onset within 2 weeks and full remission within 1 to 3 months • DSM-IV TR: sudden onset of psychotic symptoms lasts 1 day or more but less than 1 month. sweepers and maids were after her. Finally her daughter fell ill as early as 18 years of age. influenza epidemics or maternal starvation.becomes closer. These studies have shown that as relationship to the identified patient . As an added complication.. to the critical role that the environment plays in modulating genetic susceptibility in mental disorders. These ghosts also took away her thoughts.32
Psychiatry for General Practitioners
on. various combinations of genes may all lead to the same disorder. in part. they had many other symptoms and disabilities.e. As a result. risk of schizophrenia increases. This ambiguity could be due to environmental influences or interactions with other genes. favoured her and directed her to do different things via the TV. which closed her ears to all outside sound. • Good premorbid social and occupational performance • Absence of blunted or flat affect • If the combined duration of symptomatology exceeds 6 months. Familial risk has been documented through twin studies. do not share the disorder). They threatened her. which use two types of twin pairs for exploring the role of inheritance that is. This risk increases from 1% in the general population to nearly 50% where both parents are schizophrenic or in pairs of monozygotic twins. Also.

disappear. The illness may then stop recurring. that other people put thoughts into his mind or withdraw them and make them public in some way. that other people can read his thoughts. Most people with schizophrenia do not recognise that their mental functioning is disturbed or that they need help. impulsive actions and utterances. The illness is marked by a variety of symptoms. This lack of insight worsens their suffering because they do not understand the fact that medication is a necessity for them. Symptoms of Schizophrenia “Core” symptoms Disorderly thinking Incongruity of emotion Impulsive actions and utterances Bizarre delusions (with little or no appreciation of why the ideas are not acceptable to the people around). The disease may erupt and become severe. The most prominent features are: disordered thinking which becomes incoherent. The severity of symptoms and the functioning of a person may. lasting each time for less than six months. In some people the symptoms may come and go only once. Only last for a brief period. Whether these disturbances are the cause or effect of the disease are still matters of debate. Brief Psychotic Disorder and Delusional Disorder
33
The neurotransmitter hypothesis of schizophrenia postulates either increased or disturbed production or transmission of various neurotransmitters in the brain. catecholamines and Gamma Amino Butyric Acid (GABA). Hallucinations (hearing threatening or unfriendly voices. however. The most researched among these are Dopamine. where a person begins to hear voices. incongruity of emotion. Sufferers may also perform strange movements. are fortunate to experience a gradual decline in symptoms. or insidious and gradual. Paranoid thoughts (the beliefs that one is surrounded by hostile forces which keep a close watch and secretly intervene to harm). Thought insertion and thought broadcasting (the person feels that his thoughts are not his own. About 25 per cent people with schizophrenia become symptom-free in their later lives. and appear again after some time. Passivity feelings (the person is convinced that his actions are controlled by an alien power). This is called schizophreniform disorder. where none exist). and hallucinations. often of unfriendly kind. disjointed and rambling.Psychoses: Schizophrenia. wax and wane. Some people. Symptoms Onset of illness may be sudden even catastrophic.
. or that his thoughts are being said aloud or broadcast on radio or TV). Sudden onset sufferers generally have a better prognosis. as they grow older. In most people the disease runs a long and continuous course. Bizarre delusions is another common feature. or sees objects that do not exist. but may again become placid.

Somatic type – Delusional parasitosis. Persecutory.34
Psychiatry for General Practitioners
Incoherent bizarre behaviour Incoherent. or rambling speech Abnormal posturing or movement Difficulty in coping with home and work <http://www. A patient complained of mobile jammers closing up his insides so that he could not pass stool! Another believed that strangers from space had passed some kind of rays into his brain because of which his brain stopped working. Jealousy. Erotomanic/Amorous. goversentrezquery.
. She/He may also believe that others are controlling his thoughts or that his own thoughts are being broadcast to the world so that other people can hear them. Delusional disorder: Presence of non-bizarre delusions lasting for more than 1 month without prominent hallucinations.nih. Grandiose. it is important to look at its characteristic symptoms: Delusions Delusions are false ideas or beliefs that may sometimes be believed for short periods of time. Delusions may be of grandeur. symptoms of almost all other mental illnesses in one form or other. disjointed. or even extremely bizarre. at some time or other) Difficulties in money management Severe distrust or suspiciousness Compromised learning ability Poor memory Physical violence Risk of harming self Poor grooming and hygiene To develop a clearer understanding of the illness. Dysmorphic delusions.nlm. their persistence and bizarreness eventually can only be explained on the basis of illness. However. power or persecution.ncbi. Body odour (Bromosis).fcgi? cmd=Retrieve&db=PubMed&list_uids=10655007&dopt= Abstract>-related responsibilities Associated symptoms Unexplained physical tiredness Poor concentration Sleeping problems Appetite problems Diminished sexual interest Overly dependent behaviour (In short.

or may engage in constant. laugh suddenly without explanation. coats. They may suddenly stop talking in the middle of a conversation. They may jump from topic to topic or string together loosely associated phrases. In addition. smell. abstract thinking. Since there are no blood or laboratory tests:
. or may display clearly inappropriate sexual behaviour such as masturbate in public (extremely rare in our population). are especially common: including two or more voices conversing with each other. may shout or swear without provocation. Diagnosis Schizophrenia is diagnosed by its psychopathology—abnormalities in thinking and perception as inferred by the person’s speech and behaviour. their speech may become incoherent or nonsensical. Other symptoms People with schizophrenia may face difficulties with memory. such as hearing voices when no one else is around. In rare cases. or slow speech. This lack of volition stops him from initiating and pursuing goal-directed activities. decreased emotional expressiveness. depression. and talking in a low. Disorganised thinking and speech Since speech is the mirror of thought. wear multiple shirts. or taste things that are not really there. Bizarre behaviour A person with schizophrenia may appear disheveled. Social withdrawal Several “negative” symptoms may occur—the most characteristic being social withdrawal— avoiding others. become overly dependant. may walk backward. oddly dressed (for example. avoid eye contact with others. voices that continually comment on the person’s thoughts or behaviour. and thought processes are fragmented or disorganized. monotonous voice. suffer a loss of sexual interest. random or repetitive movements. bizarre pose for hours. and face problems in money management. Hallucinations must occur in clear consciousness.Psychoses: Schizophrenia. feel. They commonly suffer from anxiety. and display a blank facial expression. make strange faces. They may also combine words and phrases in meaningless way or make up new words. or voices that command the person to do something. Brief Psychotic Disorder and Delusional Disorder
35
Hallucinations People with schizophrenia may also experience hallucinations (false sensory perceptions). may oversleep or find difficulty in sleeping. they may show “poverty” of speech (either less words or less ideas conveyed through words). They may experience physical tiredness for no valid reason. scarves and gloves or use inappropriate make up). and suicidal thoughts. and may see. In severe cases muteness—no speech at all—may intervene. attention span. Auditory hallucinations. may talk to himself. and planning ahead. He may also have difficulty in experiencing pleasure and may not participate in any work or social activities. hear. he may maintain a rigid.

or violence towards others. anti-parkinsonian. and careful mental status examination. endocrine. Many leave home and are lost and others remain disabled. • Lipid profile. especially in the West and especially of nicotine. XYY. • ECG and X-ray chest. Hallucinations. XXY. Wilson’s disease. Diagnosis of Schizophrenia: Delusions. the worse is the outcome. The disease progresses if left untreated. • Fasting glucose. head • EEG and MRI as needed • HIV and syphilis tests when needed. the better is the prognosis.
. • Metabolic-systemic diseases: infectious. Investigations • Careful history and full physical-neurological examination • Complete Blood Count. The longer the duration of untreated psychosis. Laboratory Test and Differential Diagnosis Individual symptoms of schizophrenia can occur in a diverse number of illnesses–for example. there is poor intermediate and poor long-term course. it may result in incorrect or harmful treatment. Disorganised speech. inactivity and slowness become sources of distress to both sufferers and their families. aqueduct stenosis. developing an independent diagnostic test. Some may be totally withdrawn and uncaring of themselves and others. Grossly disorganised/catatonic behaviour. familial basal ganglia calcification and others. AIDS. Egocentric (Western) cultures traditionally are more stressful for men and here they show worse prognosis. steroids. Onset and Course of Illness Western research describes men as having mostly unimodal onset of positive symptoms with peak incidence from 18 to 25 years of age. Course of illness is said to be more benign in females perhaps because Estrogen modifies course or because females show better response to antipsychotic drugs. those caused by head trauma or a brain infection. Where the onset is insidious. There is also higher risk of drug abuse. The more acute the onset and later the age of onset. and several others. The onset of schizophrenia among women is said to be bimodal. Differential diagnosis • Drugs: of abuse. • Genetic-chromosomal phenocopies: Huntington’s. Relatives are confused wondering if the person is ill or just pretending. as behaviour may swing from normal to abnormal. deficiency.36
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a detailed history of mental and physical disorders in the individual and his family. with the first peak between 20 and 25 years of age and second peak after 40 years of age. alogia. syphilis. avolition). preferably laboratory based. XXX. antihypertensives. NSAIDs. antidepressants. There is increased risk of self harm or suicide. are essential for diagnosis. autoimmune. The deficit form of schizophrenia with mainly negative symptoms is predominantly a male disease. chorea. Renal and Thyroid function tests. Up to 10% of patients commit suicide and up to one third attempt it at some point of the disease. Therefore. • Brain injuries or disease: CV episodes. • Mood disorders. • Liver. tumour. If a misdiagnosis occurs. is a priority research area for this disease. Negative symptoms (affective flattening. Poor self care. trauma. Electrolytes.

• Atypicals/Newer: Thioridazine. Similar to other classes of drugs antipsychotics show several different types of side effects. Olanzapine. older antipsychotics can be tried. The mainstay of treatment in schizophrenia are drugs mainly antipsychotics. But even in developing countries up to half the sufferers may remain unemployed and dependent. Lastly during the stable or maintenance phase the patient is in remission. Flupenthixol. bradykinesia. maintain the achieved clinical effect and to prevent relapse.
. Parkinsonian: Dystonias: Akathisia: Tardive dyskinesia: Motor side effects of antipsychotic drugs Tremor. Among resistant cases Clozapine may be considered under strict monitoring of blood count parameters. Trifluoperazine. This illness is said to have a better outcome in developing rather than in industrialised countries. Risperidone. induce remission. Brief Psychotic Disorder and Delusional Disorder
37
This is not a self-limiting disease. as this drug can cause fatal leucocytopenia. Newer antipsychotics are now the first drugs of choice.Psychoses: Schizophrenia. Antipsychotic drugs antagonise postsynaptic dopamine receptors in the brain and are useful to manage acute positive psychotic symptoms. as ups and downs may occur in the course of the disease. festinant gait. or there are various life stresses. the aim is to consolidate therapeutic gains as risk of relapse increases if treatment is stopped. Clozapine. Other modes of administration such as long acting injectable antipsychotics or mouth dissolving oral medication can also be tried. Ziprasidone. Uncooperative patients may need home visits and treatment in the home setting. Management and Treatment In the acute stage—lasting usually for 4–8 weeks—the chief aim is to control acute psychotic symptoms. rigidity. This is because most antipsychotics are broadly similar in efficacy and differ mainly in their side effect profiles. Quetiapine. The economic and human costs of this illness are high the world over. restlessness Abnormal involuntary movements of face. spasmodic torticollis. Aripiprazole • Long Acting Injectables: Fluphenazine. Clopenthixol. Flupenthixol. and the aim is to prevent relapse and improve level of functioning. Some antipsychotic drugs available in India • Typicals: Chlorpromazine. Haloperidol. respiratory muscles. and side effect profile of the drug. During the subsequent stabilisation phase. Most common especially with older antipsychotics. Individual selection is based on history of response to a drug. If there is no response. They may also need to be brought to hospital either after preliminary treatment at home or (if dangerous to self or to others) under police escort. Haloperidol. preference for a particular drug or mode of administration. oculogyric crisis Movement. limbs. motor side effects (table below) are seen while newer ones cause different metabolic side effects. to diminish anxiety. Non-progression does not mean cure. Risperidone. rigid posture Tongue protrusion. ophisthotonus.

patients may regain some degree of social and occupational competence and become less disruptive and easier to manage. better adjustment in adolescence. With each episode. Later on.38
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Other common side effects (newer antipsychotics) Sedation. Other predictors of good outcome were: being married. In general studies clearly demonstrated the effectiveness of social skills training procedures in improving specific behavioural social skills as well as more global measures. the pressures and expectations that patients impose on themselves and those which others impose on them improves performance. Psychotherapy should focus on education about illness. Role of Psychotherapy. Weight gain. Studies state that 55% of sufferers show moderately good outcomes and 45% have more severe outcomes. Nevertheless the majority will continue to experience various symptoms and to have social and cognitive disabilities. The relationship between social competence and psychiatric disorder has been known for quite some. Increased risk for cardiovascular disease. the most important predictors of good outcome were origin from a developing centre and acuteness of onset. Working with the entire family from time to time helps both patients and careers and helps to
. Effective and earlier initiation of pharmacological treatment makes considerable difference in early course and a modest impact on long-term course. Family Therapy and Vocational Rehabilitation Rather than formal psychotherapy. patients seem to lose something that they do not recapture. Educational and supportive family interventions have an important effect on relapse prevention. Use of structured but realistic activity schedules and programmes. Outcome Therapeutic advances over the last four decades have enabled most persons with schizophrenia to live in the community. This involves setting a target well beneath a patient’s capability in order to enable him to attain it. Reducing rather than increasing. considerable amounts of patience and perhaps most importantly the ability to allow the patient to proceed at his own pace would be the best strategy for success. The prophylactic use of antipsychotics reduces relapse rates. more frequent contacts with friends and no use of street drugs. strategies for coping and social skills training. It also helps to reduce disinterest and passivity. Families are important allies of professionals in the management of schizophrenia. hyperlipidemias and new onset type II diabetes mellitus. It is essential to continue pharmacological treatment because stopping medication often precipitates relapse. supportive psychotherapy has a definite role to play to improve symptoms and enhance quality of life. During the first 5 to 10 years patients may have multiple exacerbations followed by a Plateau phase where there is underlying deterioration. of female gender. Each successive episode requires longer returning to a remitted state. In several World Health Organisation studies on outcome. Hence multiple relapses are detrimental to overall outcome. The technique of paradoxical intention may be useful.

hostility. Such groups now growing in India too support members. Family advocacy and mental health consumer movement has been especially active among sufferers and carers of schizophrenia. Vocational rehabilitation is the most important aspect of psychological intervention in schizophrenia. over involvement). dispel myths about the illness and improve treatment standards. This is because schizophrenia patients have a low level of job retention both due to the disease process itself as well as due to stigma. provide education. It also helps to reduce heavy burden of caring for chronically ill. Brief Psychotic Disorder and Delusional Disorder
39
prevent negative familial affect (criticism.
. Supported employment programmes. individual placement programmes that immerse and support patients at the job site are the need of the hour in India. They have played an important role in improving health care conditions for the mentally ill as well as for reducing the stigma associated with mental illness.Psychoses: Schizophrenia.

severe and persistent psychiatric illnesses.” Expansive mood/affect: Expression of one’s feelings without restraint. depression. Symptoms vary between patients and in between episodes in same patient. with melancholia/depression caused by excess of ‘black bile’ and mania by excess of ‘yellow bile’. Classically. or unease. Greek thinking reflected ‘humoral’ theories. periods of prolonged or profound depression alternate with periods of excessively elevated and/or irritable mood (known as mania). It is one of the most common. Attention has to be paid both to patients’ and third party information from family and friends. In 19th century Jules Baillarger described ‘la folie a double forme’ and Jean Pierre described ‘la folie circulaire’. Mania/manic episode: see diagnostic criteria.Mania and Bipolar Affective Disorder
41
Depressive episode Prophylaxis Psychotherapy Psychoeducation Out-patient follow up Relapse prevention Specific issues Suicidality Concurrent medical problems Special patient groups Prognosis Introduction History Bipolar affective disorder has been known since ancient times. Dysphoria: An emotional state characterised by anxiety. Depressive episode: see diagnostic criteria.
. Dysphoric mania: is “prominent depressive symptoms superimposed on manic psychosis. frequently with an overestimation of one’s importance. Euphoria: Intense elation with feelings of grandeur. and Emil Kraepelin comprehensively described ‘manic depressive insanity’. Definitions Euthymia: A normal positive range of mood states implying the absence of depression or elevated mood. Hypomania/hypomanic episode: see diagnostic criteria. Often associated with grandiosity. A state of feeling unwell or unhappy.

Seasonal affective disorder: A variant of bipolar disorder.3–1. deaths. • Neuroendocrinal dysfunction (HPA axis): Given the effects of environmental stressors and exogenous steroids. Psychosocial • Stressful life events (major loses. Mode of inheritance remains unknown. • Mean age of onset 17–25 years.) Mixed episode: Occurrence of both manic/hypomanic and depressive symptoms in the same episode. but may be vice versa). with few periods of euthymia (i. • Pre-morbid personality types that use internalising rather than externalising defense mechanisms. • MZ twins: 33–90% concordance. • Male = Female. disappointments. 0. Rapid cycling: four or more episodes (of any type) in a year.. • Age range 15–50 + years (peaks at 15–19 years and 20–21 years. schizoaffective and bipolar illness. with consistent seasonal pattern to occurrence of episodes (usually winter depression and summer/spring mania. • DZ twins: 23%. (bipolar II and rapid cycling more common in females). with duration of 2 or more years. Etiology Factors identified as important include: Genetic • First degree relatives: 10–15% risks. • Abnormalities of biogenic amine metabolites. every day for at least 1 week (DSM-IV TR) or 2 weeks (ICD-10).5% (0. Genetic liability appears shared for schizophrenia. Biochemical • Dysregulation of neurotransmitters at brain synapses: Noradrenaline (NA).5% bipolar II).42
Psychiatry for General Practitioners
Cyclothymic disorder: A chronic disorder. never symptomfree for more than 2 months. role has been suggested for glucocorticoids and other stress related hormonal responses.8% bipolar I. serotonin (5HT) and dopamine (DA) all have been implicated. Epidemiology • Lifetime prevalence: 0.e. Numerous hypomanic and minor depressive episodes. • Children of one parent have a 50% chance of psychiatric illness.
. mean of 21 years). divorces).

e. Dysthymic disorder. feels rested after only 3 hours of sleep). or sexually) or psychomotor agitation. expansive. Classification and Diagnostic Criteria ICD-10 criteria: Requires at least two episodes. Decreased need for sleep (e. or irritable mood. More talkative than usual or pressure to keep talking. environment. DSM-IV TR criteria: Allows a single manic episode and cyclothymic disorder to be classified as part of bipolar disorder. Flight of ideas or subjective experience that thoughts are racing.. No history of mania or hypomania. Increase in goal-directed activity (either socially. engaging in unrestrained buying sprees. Washington.g. Distractibility (i. 4. 4th ed.: American Psychiatric Association. three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: 1. manic or mixed.g. attention too easily drawn to unimportant or irrelevant external stimuli). one of which must be hypomanic. 3. 5. Defines two subtypes: Bipolar I disorder: One or more manic or mixed episodes with or without history of one or more depressive episodes. 332. Abnormal apoptosis: Abnormal programmed cell death in critical neuronal network controlling emotions. 6. 1994 : 327. No history of mania or hypomania. Depressed
. Bipolar II disorder: One or more depressive episodes plus one or more hypomanic episodes without manic or mixed episodes. • Learned helplessness. D.Mania and Bipolar Affective Disorder
43
• Negative cognitive distortions about self.. sexual indiscretions. Psychodynamic • Loss of libidinal object • Introjection of an ambivalently loved object. Inflated selfesteem or grandiosity. Summary of Manic and Depressive Symptom Criteria in DSM-IV-TR Mood Disorders Disorder Manic Symptom Criteria Depressive Symptom Criteria Major depressive disorder. Etiological theories Kindling: The older hypothesis that suggests a role of neuronal injury through electrophysiological kindling and behavioural sensitisation similar to epilepsy..C. at work or school. lasting at least 1 week (or any duration if hospitalisation is necessary) (B) During the period of mood disturbance. and life experiences. or foolish business investments) Diagnostic and statistical manual of mental disorders. 7. 2. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e. Manic episode (A) A distinct period of abnormally and persistently elevated. History of major depressive episodes (single or recurrent).

for at least 2 years (but not meeting criteria for a major depressive episode) Bipolar I disorder. but may be of any type. no manic or mixed episodes. poor quality of life • Marital disharmony. Cyclothymic disorder. changes in sleep-wake schedule. History of major depressive episodes. For at least 2 years. quality of life and relationships) 25–50% attempt suicide and 10%–15% complete. and current alcohol or substance abuse may affect the course and lengthen the time to recovery. panic. Consequences of Untreated • High % have alcohol/substance dependence • Suicide (up to 10% of bipolar patients commit suicide) • Employment problems. Manic symptoms present. financial problems • Poor health. (ii) Stress related disorders. (v) Schizoaffective disorder. Morbidity/Mortality High (in terms of lost work. (viii) Substance Intoxication (stimulants hallucinogens. productivity. but criteria not met for bipolar I. more days than not. Comorbidity is significant and increases suicidal risk—especially drug/alcohol misuse and anxiety disorder. (ii) Compulsive Disorders (Shoplifting. (iii) Impulse Control Disorders (iv) Schizoaffective disorder (v) Schizophrenia. Not required for diagnosis Adapted from American Journal of Psychiatry 159:4. History of manic or mixed episodes. phobias). (iii) Bipolar disorder. (iv) Anxiety disorders (obsessive compulsive disorder.44
Psychiatry for General Practitioners
mood. April. the presence of numerous periods with hypomanic symptoms. One or more episodes of hypomania. Bipolar II disorder.). Untreated patients may have more than 10 episodes in a lifetime. Duration and period of time between episodes stabilises after 4th or 5th episode as many as 60% of people diagnosed with bipolar I disorder experience chronic interpersonal or occupational difficulties and subclinical symptoms between acute episodes. Course It is extremely variable. (vi) Schizophrenia (negative
. 2002. bipolar II. (vi) Agitated depression (vii) Personality Disorders. opiates) (B) Psychiatric disorders (i) Dysthymia. Stressful life events. Environmental and lifestyle features can impact on severity and course. interpersonal problems Differential Diagnosis According to the episode (A) Hypomania/Mania/Mixed Depression (i) ADHD (Attention Deficit Hyperactivity Disorder). etc. First episode in females tends to be depressive and in males tends to be manic. or cyclothymic disorder. Numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. Bipolar disorder not otherwise specified. Major depressive episodes typical but not required for diagnosis. Pharmacotherapy may substantially reduce the risk of suicide.

Psychoeducation <http://www. activities.50
Psychiatry for General Practitioners
Psychotherapy Most of the therapies emphasise similar ingredients: • Identifying signs of relapse. mood). Therapies that have been tested are: Prodrome Detection <http://www. Support groups. Set limits on impulsive behaviour in patients with mania. Outpatient Follow-up Aims of OPD follow-up – Establish and maintain a therapeutic alliance Monitor • Psychiatric status [symptoms of BAD (e. eating. suicidality. Cognitive Therapy <http://www.html>. sleep patterns. Family-Focused Therapy <http://www. activity and any co-morbidities].psycheducation. substance use.org/depression/ Psychotherapy.html>. • Specific strategies to monitor moods. and • Regular daily “rhythms” for sleep. • Stress management. life events.org/ depression/Psychotherapy.html>.g.html>. making plans for early detection and response. particularly rapid cycling) • Proactively dealing with interpersonal conflict.psycheducation. high expressed negative emotions. or a member of the health care team.psycheducation. • Medical status (any co-morbidities) • Compliance (by asking family members and by doing blood levels of mood stabilisers)
. Hold family meetings to discuss issues. • Emphasis on the need to stay on medications even when well. exercise. problem-solving. • Using education to increase agreement between doctor. Interpersonal/Social Rhythm <http://www. patient and family about what it being treated and why.psycheducation. key family member or friend.psycheducation.org/depression/ Psychotherapy. Psychoeducation Targets are: • Regulating social and biorhythms (Sleep: Lack of sleep can provoke a hypomanic or manic episode) • Avoiding or regulating alcohol or substance use (Substance use may exacerbate a mood disorder.org/depression/ Psychotherapy. and improve medication adherence all promote a better prognosis • Negative attitudes towards medication in the patient.org/depression/ Psychotherapy. and focus on improving relationships.html>. reduce or contain suicidality.

or severe anxiety • Presence of alcohol or substance use
. or plans • Access to means for suicide and the lethality of those means • Presence of command hallucinations. • Identify new episodes early (identify early signs. intent. Education about the “S” that may precipitate episodes should be given— Sleep (sleep deprivation may precipitate mania and excess of sleep may lead to depression). symptoms of Toxicity) and • Blood levels of mood stabilisers Psychoeducation about Disease – • Increase understanding of signs. other psychotic symptoms. and mania in summers/spring). duration. Season (depression may occur seasonally in winters. side effects and toxicity. • Improve compliance Regularity – in rhythms of activity and wakefulness. Early or subtle signs of mania or depression should be recognised and treated (mania/mixed episodes with short-term use of antipsychotics and depression with increased doses of antidepressants). is a key part of psychiatric management. peer relationships and modification of personality traits. Relapse Prevention and Psychoeducation Helping patients to identify precipitants or early manifestations of illness. Management of long-range issues that may include marital problems. symptoms risks and biologic nature of the illness • Importance of compliance with therapy. effects. symptoms) • Increase understanding of and adaptation to psychosocial effects • Management of stress and management of work and leisure activities. so that treatment can be initiated early. sleep hygiene. eating and exercising regularly. • Limited caffeine and alcohol intake and Drugs – • Dosage. employment and financial problems. Specific Issues Suicidality Characteristics to Evaluate in an Assessment of Suicide Risk in Patients with Bipolar Disorder • Presence of suicidal or homicidal ideation. and Stress (may precipitate any type of episode).Mania and Bipolar Affective Disorder
51
• Side effects of medicines (by monitoring signs.

Pregnancy and lactation: ECT may be considered as first line as it helps in faster recovery. She did not show any impairment of memory or other cognitive functions. manic episodes of short duration. She was very agitated. psychotic features. including thyroid parameters. could not sleep. was a married lady of 27 years having two children with a family history of bipolar disorder in her father. at the age of 24 years. Physical and neurological examinations and laboratory investigations. who were jealous because of her voice and beauty. current episode mania. including stroke or other central nervous system lesion. she had an episode of depression after the delivery of her second baby. S. actors and she interrupted it only to sing and dance. Special patient groups Children and adolescents: Mania may be more chronic. good treatment response and compliance. were all normal. but oriented to time. Her endless conversation was mainly about films. In the past. Elderly: Onset of mania after age 60 is less likely to be associated with a family history of bipolar disorder and is more likely to be associated with identifiable general medical factors. with aggressive shouting. non-compliance. even smartly. The doctor observed that Mrs. poor employment history.
. She was easily distractible. talked almost incessantly and refused her food.K. place and person. long duration of episodes. male sex. S. as untreated might affect natural course of illness. jumping from one topic to another. Prognosis Poor prognostic factors: drugs/alcohol abuse. dressed. full recovery between episodes. residual symptoms between episodes. Case Vignette Mrs. She felt superior to others. and her speech was sometimes difficult to follow because she spoke very quickly. Good prognostic factors: later age of onset. Her diagnosis is Bipolar Affective Disorder. difficult to treat and may require multidrug therapy. was tidily. and the management. She was taken to the hospital because she was very excited and talkative for 2 weeks. few co-morbid physical problem.52
Psychiatry for General Practitioners
• •
History and seriousness of previous attempts Family history of or recent exposure to suicide
Concurrent medical problems Assess and treat accordingly. She was very talkative. She appeared excited and irritable.K.

depressive disorders are categorised as depressive episode (when it is the first episode). when persistent and pervasive. manic depressive psychosis (MDP). recurrent depressive disorder. once this emotional state becomes unusually long.e. Historically a number of different terms have been used in relation to the depressive illness. Minor depressive disorders are equally common. Depressed mood. We all become depressed at one time or other in everyday life depending on the circumstances.6
Depression in General Practice
Introduction Depression is one of the commonest psychiatric disorders. Most of these now have more or less historical significance. unipolar and bipolar depression and melancholia. depressive episode occurring in bipolar affective disorder and dysthymia. In the current classificatory systems. Most patients present in primary care with somatic symptoms. depending on severity. may be accompanied by a number of signs/symptoms and then becomes an illness i. moderate and severe. it could be abnormal. endogenous and reactive depression. Depression or depressed mood is a normal emotional experience in everyday life. It is a major public health problem and has also been identified as a leading cause of disability in the recent World Health Organisation—World Bank study of Global Burden of Disease. A large number of cases remain unrecognised. These include manic depressive illness. depressive disorder.
. Most of the patients often present in primary care settings rather than to a psychiatrist. Epidemiology Lifetime prevalence of major depression is 10–25% in women and 5–12% in men with one year prevalence of 5%. psychotic and neurotic depression.. However. A major proportion remains undetected leading to chronicity and disability. The individual episodes are further classified as mild.

impairment of concentration presenting as forgetfulness and ideas of hopelessness. the moderate and severe depression are further categorised as with somatic or psychotic symptoms. disturbances of appetite and sleep. A pervasive depressed mood and disinterest or inabilities to experience pleasure in activities which one enjoyed earlier are the key symptoms. early morning insomnia or increased sleep in a few). Depression is an episodic illness. losing interest in day to day activities. The patients more often present with somatic symptoms like aches and pains or pain affecting other body areas like head. Antidepressants tend to correct the disturbance. loss of weight (increased in few). death wishes and suicidal ideation. back. if the clinician is observant and specific questions are asked.54
Psychiatry for General Practitioners
Aetiology Deficiency of neurotransmitters like NE. Differential Diagnosis A number of prescription medications and common substances of abuse. it is called recurrent depressive disorder. neck or chest. Chronic antidepressant treatment through regulation of cAMP Cascade could reverse or prevent such neuronal damage and atrophy of damaged or vulnerable neuronal populations. Clinical Picture Depression can occur at any age. slowing of movements and thinking (psychomotor retardation) or psychomotor agitation.
. lethargy. Depression is further categorised into mild. Depressed mood is the central feature and all other symptoms are secondary to it. depending on their presence. helplessness. If recurrent episodes are occurring. depending on the severity of dysfunction and number of symptoms. sleep disturbances (difficulty in initiating sleep. and medical conditions are associated with depression. changes in appetite mostly reduced. serotonin. Both or either of these two symptoms should be present throughout the day on most of the days for at least 2 weeks along with other symptoms for making a diagnosis of depression. The primary care physician who is often dealing with physically ill patients needs to be observant about these causes of depression. The chronic patients or patients suffering a relapse might present with the core depressive symptoms like feeling depressed and low. There may be a history of over dosage or suicidal attempts in the past. Other symptoms include fatigue/loss of energy. frequent disruptions in sleep in midnight. ideas of self reproach and guilt. and dopamine in limbic system is responsible for the illness. neuronal atrophy and cell deaths of specific neuronal populations have been found in hippocampus and prefrontal cortex. There is a definite change from normal functioning. worthlessness. Usually it is possible to elicit depressed mood or feelings of disinterest. which could easily be passed on as indicating a physical illness. Similarly. In cases of chronic and recurrent depression. moderate or severe.

Hypo-and hyper-parathyroidism. indomethacin • Antibacterials If the patient is on these medications and the depressive symptoms have started after these were prescribed. Symptoms are not severe enough to make a diagnosis of depression.Depression in General Practice
55
1. Huntington’s Disease Cerebrovascular disease: Stroke Metabolic: B12 deficiency Endocrine: Hypo-and hyper-thyroidism. Disturbance of sleep and appetite are often present. Medical Conditions Causing Depression A number of medical conditions may present with depressive symptoms. propranolol. Some of the common medical illnesses associated with depression are listed below: Degenerative neurological conditions: Parkinsonism. Symptoms should be present for at least 2 years before a diagnosis of dysthymia can be made. Drug Induced Depression Some of the common prescription medications and substances of abuse known to cause depression include: • Antihypertensives: Hydralazine. L dopa • Analgesics: Ibuprofen. hepatitis Malignancies: Carcinoma pancreas. Mixed Anxiety Depression Mixed anxiety depression is more often seen in general practice rather than in psychiatric practice. but each category not
. if possible. In such a situation. reserpine. benzodizepines. attempt should be made to shift to an alternative. 2. Onset is usually in adolescence or early 20s. in which the patient usually presents with depressed or irritable mood for many years. Other Depressive Disorders Dysthymia Dysthymia is a chronic depressive illness. opioids • Alcohol • Steroids • Antineoplastics • Neurological agents: Amantadine. hypo-and hyperadrenocorticism Auto-immune disorders: Systemic Lupus Erythematosus (SLE) Viral and other infections: HIV. Alzheimer’s. Symptoms both of anxiety as well as depression are present. methyldopa • Sedatives and hypnotics: Barbiturates. bromocriptine. chances of these medications being responsible for depression are high. The patient more often feels tired and lethargic.

blurring of vision. 5.56
Psychiatry for General Practitioners
sufficient for the individual diagnosis. Both pharmacological as well as non-pharmacological approaches are used for treatment. The patients frequently present with vague somatic symptoms along with a mixture of anxiety and depressive features. Clomipramine. Mianserin. Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs): Venlafaxine. but differ in the side effect profile. Reversible Inhibitors of Monoamine Oxidase (RIMAs): Moclobemide. After a single episode. Serotonin-2 Antagonists. The tricyclics have severe anticholinergic (dryness of mouth. 50–85% patients have a second relapse and 80–90% of those who have had a second episode would have a third episode. Individual variations are observed in the response to medication. Fluvoxamine. Heterocyclic Antidepressants: Imipramine. Dothiepin. Heterocyclic Antidepressants Heterocyclic antidepressants are the oldest group of antidepressants. 1. The starting dose of imipramine and amitriptyline is 75 mg in 2–3 divided doses. urinary retention etc. The drugs reduce the chances of relapse and improve quality of life and disease associated disability and burden. Doxepin. 2. it can be treated effectively. Nefazodone. Amoxapine. Duloxetine. The group includes the conventional tricyclics.
. Citalopram. 6. Norepinephrine and Serotonin Specific Antidepressant (NSSA): Mirtazapine. Management Depression can be easily identified and diagnosed. Trazadone. The maximum dose is 250–300 mg/day. Nortriptyline. weight gain and sexual dysfunction. Sertraline. which is gradually built up to 150 mg in 7–10 days time. Escitalopram. 7. Up to 15% of depressives end their life by suicide. Norepinephrine Reuptake Inhibitors (NRIs): Reboxetine. Once diagnosed. Course and Prognosis Depressive disorders often run an episodic course and tend to recur. A list of antidepressants available currently in India is given below: 1. 3. Amitriptyline. antiadrenergic (postural hypotension). Tricyclics like imipramine and ammtriptyline were the most commonly used antidepressant till early 1990s. if the primary care clinician is observant and carries a high rate of suspicion especially when dealing with patients presenting with unexplained physical symptoms. sedation and cardiac side effects. but there is always a lag period of 2–3 weeks for response to start: Most have nearly equivalent efficacy. Pharmacological Management A wide variety of effective drugs. A.). The efficacy of this group of drugs is unquestionable. constipation. Paroxetine. Serotonin Specific Reuptake Inhibitors (SSRIs): Fluoxetine. 4.

Serotonin Specific Reuptake Inhibitors (SSRIs) SSRIs are often the drugs of first choice for treatment of depression. fluvoxamine. Amoxapine is another tetracyclic. Escitalopram is an isomer of citalopram. Lowest dose is often the therapeutic dose and most of the patients respond to this dose. headache and sexual dysfunction. 2. which have reduced its use.
. usually in the morning after breakfast because of their tendency to induce insomnia and gastric distress. Higher doses are associated with elevation of BP making it not a preferred drug for patients with hypertension.5 mg per day and gradually increased to 150 mg per day after 1–2 weeks.
Table 1: Doses of SSRIs SSRI Fluoxetine Sertraline Fluvoxamine Paroxetine Citalopram Escitalopram Dose in mg per day 20–80 mg 50– 200 mg 100–300 mg 20–50 mg 20–50 mg 10–20 mg
However. Doses of different SSRIs are given in Table 1. sertraline. Out of the various SSRIs. The extended release preparations are also available for once a day used. which is given in 2 divided doses). agitation. Maximum dose is 300 mg per day. Currently 6 SSRIs (fluoxetine. SSRIs have a long half-life and are therefore usually given as a single dose (except fluvoxamine. vomiting. 3. Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) Venlafaxine and duloxetine are two SNRIs currently available in market. dyspepsia.Depression in General Practice
57
Mianserin is a tetracyclic antidepressant used in dose of 30–60 mg/day usually as a single dose. • Common side effects include nausea. anxiety. Venlafaxine is started in dose of 37. citalopram and escitalopram) are available. There have been reports of blood dyscrasias associated with the use of mianserin. citalopram and escitalopram have minimal drug interactions and therefore are safer in patients on treatment for physical problems. in severe depression SSRIs have a limited efficacy in severe depression. paroxetine. The dose of amoxapine is 150–400 mg per day in divided doses. Common side effects include sedation and giddiness. One of the metabolites of amoxapine has antipsychotic properties and it has been promoted especially in cases of depression with psychotic features.

Serotonin-2 Antagonists Trazadone and nefazodone are members of this group. given as a single dose. headache. Norepinephrine and Serotonin Specific Antidepressant (NSSA) Mirtazapine belongs to NSSA group. The MAO inhibitors and RIMAs are especially indicated in cases of non-responsive and atypical depression (patients of depression presenting with irritability. It is used in the dose of 60–120 mg/day. dizziness. sexual dysfunction. sweating. wt. nausea. Other side effects include nausea. Common side effects include sedation. dry mouth. Venlafaxine has also got efficacy in severe depression. Duloxetine is a new introduction in the filed of antidepressants. Usual starting dose is 4 mg BD. drowsiness. tachycardia and priapism. which can be increase if required. Usual starting dose is 15 mg per day. Norepinephrine Reuptake Inhibitors (NRIs) Reboxetine is a member of this group of drugs. if started in higher doses. It is usually used as a single bedtime dose.
. It is also available in form of dispersible tablets. drowsiness. Common side effects include nausea. constipation. drowsiness. Common side effects include sleep disturbance. It is used in doses of 15–45 mg per day. It does not have significant cardiovascular side effects. Most patients develop tolerance to the side effects. 6. It is better to start in dose of 25 mg twice a day and to gradually build up the dose as it can cause severe giddiness. Monoamine Oxidase Inhibitors (MAO Inhibitors) MAO inhibitors have a limited use in the current psychiatric practice because of the serious food and drug interactions. BP should be monitored. It is used in doses of 4–6 mg twice a day. 4. Out of various antidepressants. Hypertension has also been reported in some cases and may be tyramine related. a member of this group is used in doses of 150–600 mg per day in two divided doses. vomiting. Common side effects include insomnia. mirtazapine has minimal sexual side effects. dizziness. 7. dizziness. insomnia. gain. dizziness and headache. Most patients respond to a dose of 60 mg per day. 5. headache and sedation. headache. increased sleep and increased appetite). Common side effects include increased appetite. dizziness. Trazadone is used in doses of 150–300 mg per day. dry mouth. agitation and confusion. These are also not available in India. The reversible inhibitors of MAO (RIMAs) are relatively safe. Moclobemide. sedation. nausea. postural hypotension. insomnia. Many patients would respond to the lowest dose.58
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Whenever a higher dose is to be used. oedema. dry mouth. tachycardia and urinary hesitancy.

it is often difficult and confusing which antidepressant to choose. agitation and suicidality (especially in young people below 30). A preferred approach would be to start tapering off after 10–15 days. insomnia.75 mg per day in divided doses) for 2–3 weeks may be a better strategy. reassurance and use of benzodiazepines (diazepam 5–10 mg per day. triiodothyronine. change antidepressant. • SSRIs are the first line of treatment. olanzapine). • Electroconvulsive therapy (ECT) is used in patients of depression with suicidal risk. sedation. • TCAs and venlafaxine are indicated in severe depression. It is better to refer the patient to a specialist at this stage. it is better to wait and watch. Non Responding or Resistant Depression If a patient fails to respond even after taking an antidepressant for 5 weeks in adequate dose. constipation. While stopping the medication at the end of treatment. unless the patient has shown good response to another antidepressant in the past.5–0.Depression in General Practice
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Nefazodone is currently not available in India. The dose should not be reduced in the maintenance phase. the drugs should be gradually tapered of over a period of 1–3 months depending on the length of treatment. It is important to mention here that the benzodiazepines should not be used for 2–3 weeks. the following strategies may need to be used: • Check if treatment has been given in adequate dose for adequate period • If yes.
. Lorazepam 2–3 mg per day or alprazolam 0. nausea. Some general guidelines are given below: • In mild depression. It is used in dose of 300–600 mg per day. another SSRI or a drug from different group • Augmentation strategies can be used in resistant depression (Lithium. Another important point in pharmacotherapy is that the therapeutic dose and the maintenance dose are the same. dry mouth. Duration of Treatment A single episode of depression needs to be treated for 4–6 months after recovery. the treatment needs to continue for period varying from 2 years to indefinitely. In cases of recurrent depression. Common side effects include headache. dizziness. The recommended starting dose is 100 mg twice a day. be watchful in early period for restlessness. A simple counselling. weakness and light headedness. Choice of Antidepressant With a large number of antidepressants available for use. 50% patients are likely to relapse. • Mirtazapine is another good choice. If treatment is stopped immediately. • While using SSRIs. poor oral intake and psychotic symptoms.

psycho-education. Interpersonal Therapy (IPT) IPT is based on the principle that depression occurs in interpersonal context. It is based on the principle that the depression and the depressed mood are a result of faulty cognitions or maladaptive ways of thinking. Supportive Psychotherapy Supportive psychotherapy includes the components of reassurance. Non Pharmacological Management Non pharmacological approaches for treatment of depression include non-specific approaches like supportive psychotherapy. Treatment is structured and goes on for 12–16 weekly sessions. Antidepressants don’t have any dependence potential. challenging negative automatic thoughts and learning rational responses to negative thoughts. The treatment is focussed at correcting the faulty cognitions. Timely diagnosis and treatment can prevent distress and disability. Conclusion Depression is a very common illness in primary care settings. IPT is also a specific treatment for depression.60
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B . interpersonal deficits. 2. The sessions can be held in one to one format or in small groups of patients. Such fears need to be allayed. though it is now also used in a variety of psychiatric disorders. and grief or role transition. The treatment involves helping the patient identifying depressogenic negative thoughts.
. It is usually taken in form of weekly sessions spread over 12–16 weeks. Often the patient as well as the family has notions of depression not being an illness. which was especially developed for depression. Need of long-term requirement of the medication in the background of long-term nature of illness should be emphasised. The patient and family need to be educated about the illness. The efficacy is likely to last for long time and it also has prophylactic value. Many patients have an apprehension that the antidepressants may not be safe on long-term use or they might become dependent on them. it is associated with increased health care costs. It can be easily treated at the primary care level and the primary care physicians are fully equipped to treat such patients. If not treated early and effectively. It is a structured treatment and has proven efficacy. The therapy is aimed at resolving the underlying problem situation. which needs to be corrected. 1. and reassurance and specific therapies like Cognitive Behaviour Therapy (CBT) and Inter Personal Therapy (IPT). disability and burden. counselling. 3. encouragement. There is often a background of interpersonal conflicts. Cognitive Behaviour Therapy (CBT) CBT is a specific form of psychotherapy. emotional support and guidance.

Harmful Use 1. There are four important patterns of drug use disorders. including not only the medicines but also the other pharmacologically active agents. currently in use are ‘harmful use’. and ‘psychoactive substance use disorder’. affect or behaviour. This may occur either due to low threshold (i. to alter consciousness. the drug abuse is of greatest social relevance. which may overlap each other. This definition conceptualises ‘drug’ in a very broad way. A psychoactive drug is one that is capable of altering mental functioning. Withdrawal State 3. cognition. Dependence Syndromes 4. Sometimes even a low dose of the drug or alcohol is sufficient to cause intoxication. To begin with.7
Psychoactive Substance use Disorders
Almost all cultures have used psychoactive substances to facilitate social interaction. Drug addiction is a term that was used earlier for drug-dependence. or other psychophysiological functions and responses. perception. Acute Intoxication is a transient condition following the administration of alcohol or other psychoactive substance. chronic renal failure) or due to idiosyncratic
. more wealth. resulting in disturbances in level of consciousness. to heal. This is usually associated with high blood levels of the drug. Other terms.e. leisure and individual choice. World Health Organisation (WHO) defines a drug as any substance that. Our society’s expanded chemical manipulation simply represents large technical capacity.. let us understand what is a drug. These are as follows: 1. Acute Intoxication 2. Among many a ill that have plagued the human society today. may modify one or more of its functions. when taken into the living organism. has been dropped from the scientific per se for its derogatory connotation.

each time requiring a higher dose of the drug to get the same effect because of development of tolerance. The recovery is generally complete except in cases where tissue damage or other complications have occurred. Withdrawal symptoms are relieved if the drug is taken. This behaviour is detrimental to personal and social life of the individual.62
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sensitivity. withdrawal symptoms develop. The withdrawal states are further classified as: (i) Uncomplicated (ii) With convulsions (iii) With delirium 3. (iv) Evidence of tolerance is seen in dependent users. (iii) A physiological withdrawal state occurs when the substance use has ceased or reduced. In case the drug is not available or available in lesser quantity.
. The definite diagnosis of dependence should usually be made only if at least three of the following have been experienced or exhibited at some time during the previous year: (i) A strong desire or sense of compulsion to take the substance. According to the International Classification of Diseases (ICD-10). (ii) Difficulties in controlling substance-taking behaviour in terms of its onset. Withdrawal syndrome is generally short lasting ranging from few hours to few days. The dependence syndrome is characterised by a strong. the intensity of intoxication lessens and the symptoms eventually disappear in the absence of further use of the substance. (v) Progressive neglect of alternative pleasures or interests because of substance use occurs and the individual spends more time in procuring and using the psychoactive drug. 2. the person has to take the higher doses. Dependence Syndrome is a condition. termination or levels of use. behavioural. cognitive phenomena in which the use of a substance or a class of substances taken on a much higher priority for a given individual than other behaviours that once had greater value. In order to achieve the effects of the drug obtained with low doses initially. often over-powering desire to take a psychoactive drug (may or may not have been prescribed medically). he has a compulsive need to obtain and use the drug. Withdrawal State comprises a cluster of symptoms that are specific to the drug used and develops on total or partial withdrawal of the drug usually after repeated and/or high-dose use. When a person becomes dependent on a particular drug. the dependence syndrome is a cluster of physiological. which generally develops on regular and continued use of a drug. As the time passes.

. and residual and late-onset psychotic disorder.
. Phencyclidine (PCP) Sedatives and hypnotics i.. Cannabis. Biological Factors (i) (ii) (iii) (iv) (v) (vi) Genetic vulnerability Co-morbid psychiatric disorder or personality disorder Co-morbid medical disorders Reinforcing effects of the drugs Withdrawal effects and craving Biochemical factors
Contd.. Marihuana Cocaine Amphetamines and other sympathomimetic drugs Hallucinogens i. and Other stimulants i.e. The major dependence producing drugs are as shown in Table 1. Alcohol Opioids i. 10.
Table 1: Psychoactive Substances 1. driving during intoxication) The diagnosis of ‘Harmful use requires that the actual damage is caused to the physical or the mental health of the user. Biological.e. Caffeine
Aetiology of Substance Use Disorder It is a complex interplay of multiple factors that leads to this disorder.e. Lysergic acid diethylamide (LSD).Psychoactive Substance use Disorders
63
(vi) There is persistence with the substance despite of harmful effects caused by the drug on various body organs. 7. 8. If the patient qualifies for the diagnosis of dependence syndrome then harmful use is not diagnosed. Harmful Use of a drug can be classified as follows: (i) Continuous drug use. 5. 3. barbiturates Inhalants i. heroin Cannabinoids i.. 4. psychological and social factors have been implicated described in Table 2. 2.
Table 2: Aetiological Factors in Substance Use Disorders 1.. amnesic syndrome. (ii) A pattern of physically hazardous use of drug (i.e. 6. ICD-10 includes other syndromes associated with psychoactive substance use such as psychotic disorder.. despite the awareness of harmful medical and/ or social effect of the drug being used.e. volatile solvents Nicotine..e. 4.e. 9... opium.

When the blood levels reach between 400–800 mg%. there is generalised central nervous system depression with alcohol use. Later. Acute Intoxication After initial excitation for a brief period.
Complications Alcohol dependence has its effect not only on the consumer’s body but also on the social and personal life of the individual leading to several complications both medical and social. Increasing drowsiness followed by coma and respiratory depression develop at the blood level of 300–450 mg%. need for novelty seeking General rebelliousness and social non-conformity Early initiation of alcohol and tobacco Poor impulse control Sensation-seeking (high) Low self-esteem (anomie) Concerns regarding personal autonomy Childhood trauma or loss Relief from fatigue or boredom Escape from reality Lack of interest in conventional goals
(viii) Poor stress management skills
(xiii) Psychological distress 3. there is increased reaction time. slowed thinking and distractibility and poor motor control. ataxia and incoordination occur. Social Factors (i) Peer pressure (often more important than the parental factor). death is likely to occur (Table 3). Psychological Factors (i) (ii) (iii) (iv) (v) (vi) (vii) (ix) (x) (xi) (xii)
Psychiatry for General Practitioners
Curiosity. The signs of intoxication are obvious with blood alcohol levels of 150– 200 mg%.
. dysarthria. (ii) Role model: imitating the ego-ideal. With increasing intoxication. These are as follows: 1. There is progressive loss of self control with frank disinhibited behaviour. The duration of intoxication depends on the amount and the rapidity with which alcohol is ingested.64 2.

. Hypothermia. alcoholic seizures. and delirium tremens. Sometimes an individual develops complete amnesia of the acute intoxication known as blackouts. It is an idiosyncratic reaction to alcohol and not related to blood levels. Mild tremors. usually 12–48 hours after a heavy bout of drinking. irritability. The most common withdrawal syndrome is a hangover on the next morning. Multiple seizures (2–6 at one time) are more common than single seizures. incoordination. It occurs in about 2% of the cases. Often. The hallucinations are generally accusatory or threatening in nature. insomnia and anxiety are other common withdrawal symptoms. Sometimes withdrawal syndrome is more severe characterised by one of the following three: alcoholic hallucinosis. (ii) Alcoholic seizures (rum fits): Generalised tonic clonic seizures occur in about 10% of alcohol dependent patients.Psychoactive Substance use Disorders
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Table 3: Blood Alcohol Levels and Behaviour Blood alcohol concentration 25–100 mg% 80 mg% 100–200 mg% 300–350 mg% 350–400 mg% > 400 mg% Urinary alcohol concentration >120 mg% >200 mg% Behavioural correlated Excitement Is the legal limit for driving in UK while in India this limit is 30 mg% Serious intoxication. slurred speech. these patients have been drinking alcohol in large amounts on a regular basis for many years. a dependent alcoholic experiences hallucinations (usually auditory). nystagmus. dysarthria. Sometimes status epilepticus may be precipitated. Usually recovery occurs within one month and the duration is very rarely more than six months. In about 30% of the cases. (i) Alcoholic hallucinosis: During partial or complete abstinence. These hallucinations persist after the withdrawal syndrome is over. weakness. nausea. This condition is known as pathological intoxication. Withdrawal Syndrome In a dependent alcoholic when the blood levels decrease withdrawal symptoms appear. and classically occur in clear consciousness. delirium tremens follows. vomiting. 2. cold sweats Coma Death may occur Diagnostic use Suggestive Diagnostic Equivalent blood alcohol concentration 80 mg% 150 mg%
Sometimes a small dose of alcohol may produce active intoxication in some persons.

Death may occur due to cardiovascular collapse.66
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Delirium tremens (DT): It is the most severe alcohol withdrawal syndrome. hypothalamus. with a reversal of sleep-wake pattern can be seen. papillary irregularities. (b) Higher mental function disturbance: Disorientation. causing an impairment of vision. fractures’ liver disease and pulmonary tuberculosis may complicate the clinical picture. sweating. It occurs usually within 2–4 days of complete or significant abstinence from heavy alcohol drinking in about 5% of patients. intercurrent medical illness like pneumonia. 3. fever. Neuropsychiatric Complications of Chronic Alcohol Use (i) Wernicke’s encephalopathy: This is an acute reaction occurring in response to severe deficiency of thiamine. The important clinical features are: (a) Ocular signs: Course nystagmus and ophthalmoplegia. (d) Marked autonomic disturbance with tachycardia. infection. (ii) Korsakoff’s psychosis: Korsakoff’s psychosis often follows Wernicke’s encephalopathy and together they are referred as the Wernicke-Korsakoff Syndrome. mammillary bodies and midbrain. The course of delirium tremens is short and recovery generally occurs within 7 days. Peripheral neuropathy and serious malnutrition are generally co-existent. characterised by gross memory disturbances with confabulation and
(iii)
. hypertension and papillary dilatation are the usual features encountered. Neuropathological findings show neuronal degeneration and haemorrhage in thalamus. (c) Visual (and also auditory) hallucinations and illusions. This is an acute organic brain syndrome with the following characteristic clinical features: (a) Clouding of consciousness with disorientation in time and place. with bilateral external rectus muscle paralysis occur early. Clinical manifestations of Korsakoff’s psychosis include an organic amnestic syndrome. (b) Poor attention span and distractibility. In addition. (f) Insomnia. as compared to acute tremulousness which occurs in about 34% of the cases. Tactile hallucinations of insects crawling over the body may occur. (g) Dehydration with electrolyte imbalance is present. hyperthermia or self-inflicted injury. poor attention span and distractibility are the common impairments of higher mental functions. commonest cause being chronic alcohol intake. which are often vivid and very frightening. Other early symptoms seen are apathy and ataxia. The onset of this disorder characteristically occurs after a period of persistent vomiting. retinal haemorrhages and papilledema can occur. confusion. recent memory disturbances. At times. (e) Psychomotor agitation and ataxia may be present.

hallucinations. optic tract and cerebellar peduncles. • Level of current and past occupational and socials functioning should be assessed. cerebellum and parts of brainstem. This is a rare disorder. ataxia. • Look for the possibility of a psychiatric diagnosis. Another drug used is diazepam. (iv) Other complications of alcohol use include (a) Alcoholic dementia (b) Cerebellar degeneration (c) Peripheral neuropathy (d) Central Pontine myelinosis (e) Optic atrophy (particularly with methyl alcohol) Treatment Following steps should be considered before starting treatment for alcohol dependence: • Look for the possibility of a physical disorder. spastic limb paralysis. Detoxification Treatment of alcohol withdrawal symptoms is detoxification. Symptoms that are produced due to non-availability or lesser availability of alcohol to a dependent alcohol user are withdrawal symptoms and the constellation of symptoms form withdrawal syndrome. and deterioration of personality and intellectual functions. Clinical manifestations include disorientation. Neuropathological findings show widespread lesion and the most consistent changes are seen in bilateral dorsomedial nuclei of the thalamus and mammillary bodies. • Assessment of the social support the patient enjoys should be done.Psychoactive Substance use Disorders
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impaired insight. • Personality characteristics of the patient should be assessed in details. its dose being 40–80 mg per day in divided
. epilepsy. The aim of detoxification is the symptomatic management of the emergent withdrawal symptoms. The treatment comprises two broad components i. The cause is usually severe. (iii) Marchiafava-Bignami disease: This disorder is probably caused by alcohol-related deficiency with pathological changes in the form of widespread demyelination of corpus callosum.. Benzodiazepines are the drugs of choice for symptomatic detoxification. • Patient’s motivation to undergo treatment should be assessed. The usual duration of uncomplicated withdrawal syndrome is 7–14 days. 1. detoxification and treatment of alcohol dependence. Chlordiazepoxide is generally used in the dosage range of 80–200 mg per day in three to four divided doses. dysarthria. The changes are also seen in periventricular and periequiductal grey matter. untreated thiamine deficiency secondary to chronic alcohol use.e.

These drugs follow a standard dose regime with dosage steadily decreasing and stopping on 10th day. has caused devastating effects on the adolescents and the youth of the country. Nutritional deficiency is generally associated with alcohol dependence therefore. vitamins should be given. Treatment of Alcohol Dependence: After the detoxification process is over further management is done with the aim to prevent the patient from restarting alcohol consumption. Several methods are available to choose that suit best to the patient. higher doses are required for longer period (up to 10 days) In some countries drugs like chlormethiazole (1–2 g/day) and carbamazepine (600–1600 mg/ day) are also used for detoxification. Addition of heroin to Indian streets. The dried exude obtained from unripe seed capsules of Papaver somniferum is a highly dependence producing and is abused for centuries. Some of these important methods are as follows: (i) Behaviour therapy (ii) Psychotherapy (iii) Group therapy (iv) Deterrent therapy (v) Other medications (vi) Psychosocial rehabilitation Opioid use Disorder The natural alkaloids of opium and their synthetic preparations are highly dependence producing drugs (Table 4). In severe dependence.68
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doses.
. the use of opioids has tremendously increased all over the world. The typical dose of chlordiazepoxide in moderate alcohol dependence should be as follows: — 1st day 20 mg four times — 2nd day 15 mg four times — 3rd day 10 mg four times — 4th day 5 mg four times — 5th day 5 mg two times and then stop. some two decades ago. India being the transit point for illicit drug trade between golden triangle (Burma-Laos-Thailand) and golden crescent (Iran-Afghanistan-Pakistan) is among the worst effected countries. In the last few decades. 2.

epsilon and lambda. mydriasis may occur due to hypoxia. insomnia. Due to its higher addictive potential than morphine. papillary dilatation. muscle cramps. Apart from the parenteral mode of administration. reach their peak within 24–72 hours and subside within 7–10 days of the last dose of opioids. often in impure form (popularly known as smack or brown sugar in India. Acute Intoxication Acute intoxication due to opioids is characterized by apathy. tachycardia. respiratory depression. subnormal core body temperature and pin-point pupils. reflexes become delayed.
. mild hypertension. hypotension. Heroin (diacetyl-morphine) is two times more potent than morphine in injectable form. heroin causes dependence after a short period of exposure.
Morphine Codeine Thebaine Noscapine Papaverine
Synthetic Compounds
(i) Heroin (ii) Nalorphine (iii) Hydromorphine (iv) Methadone (v) Dextropropoxyphene (vi) Meperidine (Pethidine) (vii) Cyclazocine (viii) Levallorphan (ix) Diphenoxylate Morphine and heroin are the most potent dependence producing derivatives. generalised bodyache. Natural Alkaloids of Opium
(i) (ii) (iii) (iv) (v)
2. raised body temperature. they bind to mu opioid receptors. Withdrawal Syndrome Withdrawal symptoms generally appear within 12–24 hours. delta (for a type of encephalin). bradycardia. Tolerance to heroin occurs rapidly and can be increased up to more than 100 times the first dose needed to produce an effect.Psychoactive Substance use Disorders
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Table 4: Opioid Derivatives 1. In severe intoxication. Subsequently. The other opioid receptors are kappa (for pentazocine). yawning. heroin can also be smoked or chased (chasing the dragon). rhinorrhoea. pulse becomes thready and coma may occur in case of a large overdose. sigma (for phencyclidine). sweating. The characteristic symptoms include lacrimation. diarrhoea.

naltrexone) are generally used to treat opioid overdose. Detoxification 3. (ii) Complications due to intravenous use are quite common if the needles are exchanged. Chronic use also leads to financial and occupational difficulties leading to marital dicord and other social problems.. Treatment of Opioid Overdose: Narcotic antagonists (i. associated virtually with no morbidity or
. naloxone. Maintenance therapy 1. Since naloxone has a short half-life.e. septicemia. Naloxone challenge test to precipitate withdrawal symptoms and urinary opioid testing with radioimmunoassay (RIA). endocarditis. the examination and laboratory tests. pulmonary embolism. The user gets exposed to the risk of various infections. purchase and even use of opioids is illegal and is liable to be penalised with severest of punishment (under Narcotic Drugs and Psychotropic Substances Acts 1985 in India). piloerectio. Complications generally seen are parkinsonism. thrombophlebitis. causes reversal of overdose. transverse myelitis. peripheral neuropathy. Intravenous injection of 2 mg naloxone followed by repeated injection in 5–10 minutes. and managing the emergent withdrawal symptoms. After confirming the diagnosis. This is usually done by abruptly stopping the opioid. viral hepatitis. Complications Chronic opioid use may lead to several complications. skin infections. The complications generally seen are AIDS. applicable on a very large scale. Detoxification of opioid dependents is highly successful. import. Treatment Before starting treatment correct diagnosis should be established on the basis of detailed history of drug intake. There can be marked individual differences in manifestation of withdrawal symptoms. high pressure liquid chromatography (HPLC) or enzyme-multiplied immunoassay technique (EMIT). One may experience one or more of the following complications: (i) Complications due to illicit use are quite common. Withdrawal syndrome with heroin is more severe as compared to the one seen with morphine. tetanus. gas liquid chromatography (GLC). nausea. Detoxification: is the process in which a opioid dependent person is “freed” from opioids. (iii) Drug pedalling and criminal activities may become a part of chronic users’ life leading to various social and legal complications. thin layer chromatography (TLC). Treatment of overdose 2. Production. amblyopia.70
Psychiatry for General Practitioners
severe anxiety. repeated doses are required every 1–2 hour. Illicit drug is usually contaminated with some toxic additives. relatively cheaper. the treatment can proceed on three lines: 1. These tests provide an evidence of drug use. 2. degeneration of globus pallidus. General supportive care should be provided along with. The important ones are listed here. manufacture. These tests include. sale. vomiting and anorexia. free radical assay technique (FRAT). export.

It is also argued that one dependence is replaced by another. The aim is to gradually taper the patient from methadone. Clonidine causes excessive sedation and postural hypertension. to control withdrawal symptoms. Now if the person takes an opioid. while with oral administration effect appears much quicker (within 1–2 hours) and persists for 72 hours. Regular blood pressure monitoring should be done. Therefore. The usual dose of clonidine is 0.3–1. Methadone is relatively less addictive. Following methods are available for the management of the withdrawal symptoms: (i) Use of substitution drugs such as methadone is quite common though this drug is not available in India. These withdrawal symptoms are managed with addition of clonidine for a period of 10–14 days and then stopping it. (iii) Naltrexone in combination with clonidine is used for the treatment of opioid dependence. has longer half-life. therefore the treatment is ideally started in the indoor setting. Intravenous administration also produces similar results. Maintenance Therapy: After the patient is detoxified. (b) Propoxyphene (c) Diphenoxylate (d) Buprenorphine is a long-acting partial mu-agonist and is commonly used for both detoxification and maintenance treatment. Subsequently the patient continues on naltrexone alone. administered every alternate day. and it is tapered off within 10–14 days. this method can be regarded as the combination of detoxification and maintenance treatment. (e) Lofexidine is a α2 agonist like clonidine. decreases possible criminal behaviour and has much milder withdrawal symptoms when stopped. 3.Psychoactive Substance use Disorders
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mortality and acceptable to almost all patients. The patient is maintained on one of the following regimes:
. It is started after stopping the opioid. The usual dose of naltrexone is 100 mg orally. Relapse rates are quite high when methadone is stopped. Naltrexone is a orally available narcotic antagonist blocking the action of opioids in a dependent person and thus causing withdrawal symptoms. (ii) Clonidine is an α2 agonist that acts by inhibiting norepinephrine release at the presynaptic α2 receptor.2 mg per day. there are no pleasurable experiences as the opioid receptors are blocked by naltrexone. (iv) Other drugs are also used as detoxification agents. the next step is to put the patient on maintenance therapy. Its analgesic effect and delayed action and longer duration of action were first noted in animals in 1948. These are: (a) LAAM (levo-alpha-acetyl-methadol) is not in wide use for opioid dependence and its use as a long-term treatment agent began in late 1960s. With subcutaneous injection of 10–30 mg LAAM analgesic effect is produced after 4–6 hours lasting for 48–72 hours.

constriction of peripheral blood vessels and rise in body temperature and metabolic rate. increased heart rate and blood pressure. by smoking or parenterally. The commonest forms used are cocaine hydrochloride and free base alkaloid. cocaine is the most powerful reinforcer of the drug-taking behaviour. confidence. Cocaine is central stimulant. hash or hashish. increased energy. dilated pupils. depending upon the preparation available. Cocaine has started making its presence felt in India’s bigger cities. a friend of Sigmund Freud in 1884 as the first effective local anaesthetic agent. bhang etc. sometimes. found in Bolivia and Peru. which inhibits the reuptake of dopamine. charas. intranasally. crack and can be administered in the body orally. The plant carries more than 400 identifiable chemicals of which about 50 are cannabinoids. In animals. marihuana. the most active being:
Table 5: Cannabis Preparation and THC Content Cannabis preparation Hashish/Charas Ganja Bhang Part of the plant from where it is obtained Resinous exudates from the flowering tops of cultivated plants Small leaves and brackets of inflorescence of highly cultivated plants Dried leaves. Cocaine is. Both intravenous use and free base inhalation produce a ‘rush’ of pleasurable sensations. cocaine has gained popularity as a street drug. flowering shoots and cut tops of uncultivated plants Lipid soluble plant extract THC content (%) 8–14% 1–2% 1% Potency as compared to Bhang 10 2 1
Hash oil
15–40%
25
Cocaine use Disorder Cocaine is an alkaloid derived from the coca bush. used in combination with opiates like heroin (‘speed ball’) or at times amphetamines. Acute effects are due to central stimulant and sympathomimetic effects as euphoria. In an intoxicated
. In the last few decades.72
Psychiatry for General Practitioners
(i) Methadone maintenance (Agonist substitution therapy) (ii) Opioid antagonists (iii) Other methods (iv) Psychosocial rehabilitation Cannabis use Disorder Cannabis is derived from hemp plant Cannabis sativa and different parts of the plant yield the products popularly known as grass. Erythroxylum coca. along with the reuptake of norepinephrine and serotonin. It was isolated by Albert Neimann in 1860 and was used by Karl Koller.

Physical dependence is very mild if it is there but the psychological dependence is very strong. Lung damage 11. Nasal septum perforation. and create a serious psychological dependence.
Table 6: Complications due to Cocaine use The complications of chronic cocaine withdrawal include: 1. Because cocaine causes increased energy and confidence and can produce irritability and paranoia. Delirium and delusional disorder 5. functioning. Chronic effects are generally not marked if cocaine is used for 2–3 times a week for recreational purposes. and mood increase as the dose is raised from 4 mg to 30 mg major effects are observed with the dose 16 mg and above. tachycardia. grandiosity.
. Coronary artery occlusion 9.Psychoactive Substance use Disorders
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state. Less often. elation of mood. Fetal anoxia 13. Cardiac arrhythmias 8. swollen or ulcerated. In various trials it has been found that the effects of cocaine on heart. the nose can become inflamed. perforated nasal septum is also reported. A runny and clogged nose is common to be seen and that can be treated with nasal decongestant sprays. it can disrupt eating and sleeping habits. produce minor psychological disturbances including irritability and difficulty in concentration. it may lead to physical aggression and crime. Rarely. blood pressure respiratory rate. the user presents with papillary dilatation. and more often respiratory arrest. Later. A hypomanic picture with increased psychomotor activity. judgment is impaired and there is impairment of social and occupational. Myocardial infarction 10. Psychotic episode (with persecutory delusions and acytile and other hallucinations) 4. Acute anxiety reaction 2. hypervigilance and increased speech output may be present. Gastrointestinal necrosis 12. In higher doses cocaine can cause depression of the medullary centres and death from cardiac. Perceptual disturbances (especially pseudohallucinations). Taken daily in fairly large amounts. sweating and nausea or vomiting. Dependence potential varies with the route of administration. Withdrawal Syndrome Cocaine does not produce physical dependence in the sense that alcohol and heroin does but sometimes mild withdrawal symptoms such as anxiety and depression arise. hypertension. Respiratory depression 7. Seizures (especially with high dose) 6. Intravenous cocaine use is most powerful drug-reinforcer. paranoid thinking and rarely psychosis also occur in chronic users of cocaine. Uncontrolled compulsive behaviour 3.

Use of inhalants is found more common among school going adolescents and inhalation of these agents is a peer-originated and peerperpetuated activity. and those with character disorders employ inhalants in effect at selftreatment for their intrapsychic and interpersonal distress. There is a wide range of inhalants commonly abused: (i) Airplane glue (ii) Fingernail polish remover (iii) Gasoline (iv) Paint thinner (v) Liquid shoe polish (vi) Plastic cement (vii) Cleaning fluid (viii) Wax strippers (ix) Petrol (x) Kerosene oil Causes (i) Indulgence in inhalant use behaviour is generally caused by unsuccessful and unrewarding school experiences. (ii) Personality deficiencies are reported to be important predisposing factors in confirmed inhalant abusers.
. Carbon tetrachloride is so toxic that it has been removed from the commercial trade.74
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Treatment Inhalants Volatile solvents have the capacity to intoxicate those who deliberately inhale them. School-dropout is a usual consequence of inhalant abuse. (iv) Social disorganisation within the community also contribute to this practice. depression. or both. Some of the volatile solvents are the known poisons. The period of relative stimulation and of disinhibited behaviour is also similar to that of alcohol. and benzene’s use is limited for the same reason. Psychological maturation gets arrested and aberrant behaviour is not uncommon. This can result in accidental injury or death and the releasing of aggressive impulses against one’s self or others. boarderline or over schizophrenia. (iii) Youngsters overwhelmed with anxiety. Cognitive deficit may occur with extensive and prolonged inhalant abuse. Hundreds of intoxicating volatile products are available in the homes as well as market place much within the reach of adolescents and young people. Consequences (i) Psychiatric features of acute intoxication resemble those of alcohol intoxication except for its brief duration. (ii) Physical symptoms may occur due to the toxic effects of the inhalants.

First line treatment includes Bupropion (150 mg per day for 3 days and then 150 mg twice a day for 6–7 weeks). Sudden sniffing deaths have been reported. Secondline treatment includes clonidine and amitriptyline. nicotine lozenges is available. Benzodiazepine (or other sedative-hypnotic) use disorder can either be iatrogenic or originating with illicit drug use. beedi etc.Psychoactive Substance use Disorders
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Hexane and leaded gasoline can cause of a serious polyneuritis. and the latter is capable of producing encephalopathy. For tobacco-cessation. anxiety. Currently. Nicotine replacement therapy in the form of nicotine patches. the chief inhibitory neurotransmitter in the human brain. nervousness. pharmacological and behavioural techniqiues are used. Dependence. these are the most often prescribed drugs. Tobacco leaves contain an active alkaloid. which is highly toxic and develops resistance to its own action and hence highly addictive. Toluene is involved in dysfunction of kidney. Tobacco is used in smokeless form and it is smoked as cigarette. Benzodiazepines and other Sedative-Hypnotic use Disorder These drugs are generally used in the treatment of anxiety and insomnia. nicotine spray. thereby indirectly increasing the action of GABA. Behaviour therapy and counselling are used along with pharmacotherapy or independently. Metallic spray paints and other aerosols may have dangers caused by secondary ingredients rather than by solvent themselves. nervous system and bone marrow. Tobacco plant is a native of Americas and was brought by the European navigators on their discovery of Americas in 1492. Benzodiazepines produce their effects by acting on benzodiazepine receptors (GABA-Benzodiazeine receptor complex).
. can occur and tolerance is usually moderate. both psychological and physical. insomnia. increased weight. restlessness. Intoxication and Complications Withdrawal Syndrome Treatment Tobacco Tobacco is a plant product derived mainly from Nicotiana tobaccum and Nicotiana rustica grown all over the world and used by people in almost all countries. Ventricular fibrillation and other arrhythmias occur. Chlordiazepoxide was discovered by Sternbach in 1957 and since then benzodiazepines have replaced other sedative-hypnotic drugs. Withdrawal symptoms include.

and anxiety are adaptive responses. Fear also has an adaptive function. In the sense the both fear and anxiety are alerting in nature. and psychological strengths. sweating. Anxiety has an adaptive function too. and prepare us to cope with danger. the muscles become more tensed. Species that have learnt to fight well or flee well. apprehension. the body becomes “primed” for a quicker response. Fear is in response to external danger or threat. The typical physiological response to fear prepares the body for such a fight or flight response. It warns us of impending danger. or fear of a man with a gun.8
Anxiety Disorders
Introduction Anxiety is a common emotion that we experience almost daily. both fear. as in fear of a dog. tightness in the abdomen. Fear is also an emotion we are all familiar with. pupils dilate so that the eyes can see better. whereas anxiety is in response to internally perceived danger or threat. an encounter with the boss. muscular tension and restlessness. Anxiety is characterised by a diffuse vague sense of unpleasantness. There may be different constellations of physiological responses to the anxiety in different people. accompanied with autonomic symptoms like palpitation. and the other is the awareness of being nervous. Anxiety is an alerting signal. So fear is an important emotion. The extent to which an individual is able to cope with a certain anxiety depends on the nature of the threat and the person’s coping mechanisms. particularly for the preservation of life. When we see danger we either fight it or run away from it. and primes us to deal with the danger. the breathing becomes faster.” In a state of anxiety a person’s cognitive or intellectual skills may also be
. One could say one is living in an ‘age of anxiety. The heart beats faster.’ Appearing for an examination. Anxiety is similar to fear. One is the awareness of physiological sensations like increased heart rate. Anxiety may also be associated with a feeling of shame—that “others will recognise that I am afraid or anxious. have survived. all can lead to anxiety. choking. getting a parking ticket. meeting new people. The experience of anxiety has two components.

castration anxiety and superego anxiety are hypothesised to develop at various stages of growth. and the neurochemical correlates of anxiety. the duration. Social phobia and specific phobias 3. DSM-IV Classification of Anxiety Disorders 1. Anxiety also may be the result of catastrophic misinterpretation of benign arousal sensations. work by affecting the GABAergic neurons. The behavioural theory of anxiety proposes that anxiety is a conditioned response to environmental stress. The behaviourists have been able to come up with the most effective nonpharmacological treatments for anxiety disorders. The neuroanatomical structures involved in the processing of anxiety are the amygdala. a person may misinterpret benign arousal sensations. Etiology and Pathology of Anxiety Psychoanalytically. separation anxiety. The biological basis of understanding anxiety disorders is by studying neuroanatomical structures involved in anxiety. Acute stress disorder 6. there are changes in the conceptualisation of anxiety in each new edition.
. The neurochemical mediators of anxiety are through Gamma Amino Butyric Acid (GABA) mediated inhibitory pathways. Obsessive compulsive disorder 4. Substance induced anxiety disorder 9. or may have faulty or selective recall of stressful situations. In the Diagnostic and Statistical Manual of Mental Disorders. Glutamate mediated excitatory pathways and some neuromodulation by serotonergic pathways. Anxiety disorder not otherwise specified including mixed anxiety depressive disorder. Most benzodiazepines. For the clinician it is important to distinguish between normal and pathological anxiety. the severity and the frequency of symptoms are far in excess of what would be considered as a normal response to a danger or threat. Anxiety as An Illness In recent times. anxiety is being recognised more and more as an illness.Anxiety Disorders
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affected—there may be a tendency to catastrophic thinking. Pathological anxiety is clearly out of proportion to the degree of stress. There has been a moving away from the psychodynamic concept of a neurosis to a classification based on clinically recognisable criteria. Panic disorder with and without Agoraphobia 2. Anxiety disorder due to a general medical condition 8. Generalised anxiety disorder 7. anxiety is the result of poor conflict resolution or repression of an unacceptable drive or impulse. Posttraumatic stress disorder 5. Impulse anxiety. which are excellent antianxiety drugs. the thalamus and other structures in the limbic system comprising what is called the fear network.

The patient shows persistent concern about more attacks or their implications. Almost 90% of panic disorder patients have co-morbid illness like other anxiety disorder. open-ended interview is the most important tool for establishing a diagnosis of panic disorder. and nearly 20–30% remain unimproved. spontaneous. breathing retraining is most effective in patients with panic disorder. attending parties. in fact phobias are the most common of all mental illnesses. men more likely to have panic alone. Women are twice as more likely to be affected. A detailed. Patients with panic disorder have poor quality of life due to the utterly incapacitating nature of their illness. relaxation training. paroxetine. Women have more agoraphobia. and are more likely to self medicate with alcohol or other prescription drugs to cut off the panic attack. Social Phobia and Specific Phobias Phobias are most common anxiety disorder. almost 40–50% have improved but still have significant symptoms. Meeting new people. interacting with them socially. it is only recently that they have been recognised as a separate diagnostic entity. The illness follows a chronic non-remitting course. Most of them go unrecognised or untreated because the person suffering from them does not feel the need to seek treatment. and often undergo long repeated costly investigations to rule out what they imagine as a serious heart ailment. there is a high suicide risk. Treatment is with tricyclic antidepressants like imipramine and amitryptiline. and last more than a month. mood disorders. Although social phobias are very common. Panic disorder patients are the most frequent users of the emergency services.
. the percentage may be as high as 10% to 60%. substance use disorder or personality disorders. Cognitive behaviour therapy with a lot of psychoeducation. alprazolam. Onset of the illness is in late teenage. or a sudden death situation. dealing with people in authority. If untreated. Social phobia is a marked and persistent fear of one or more social or performance situations in which a person is exposed to unfamiliar people or to possible scrutiny of others. eating or writing in front of others. The possibility of dependence on benzodiazepines is very high. are all situations where a person with social phobia will be greatly stressed. repeated rounds of investigations should be avoided. speaking formally. or is cued by a situation. with only 30% patients showing symptom remission. so the drug use should be closely monitored. But in populations who actively seek treatment. meetings. lorazepam etc and most importantly SSRIs like Fluoxetine. Most of them have impaired social and occupational functioning. Lifetime prevalence of panic attacks is 1% to 4%. benzodiazepines like diazepam. or 25 to 30 yrs. etc. The panic attacks are recurrent.78
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Panic Disorder with or without Agoraphobia Panic is a paroxysmal occurrence of intense fear or discomfort which is either completely unexpected. sertraline. After ruling out general medical disorders which could mimic a panic attack.

More women than men have OCD. unwanted ideas. The most important goal of therapy should be to reduce fear and phobic avoidance to manageable levels. and involving disturbances in orbitofrontal cortex. 63% monozygotic twins are concordant for OCD. that are intended to reduce the anxiety of obsessions. In some patients. The patient also recognises it as an unreasonable response.Anxiety Disorders
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Specific phobias are a marked and persistent fear of a specific object or situation. body dysmorphic disorder etc. Social phobias are found in 2% of the population. for natural environment like water bodies. lifts etc. But behaviour therapy and cognitive behaviour therapy are the most effective treatment options. of which depression is the most common. The patient may feel guilty about the obsessive thoughts especially if the thoughts are religious or sexual in nature. These may be a different group of disorders with imbalance in the serotonergic dopaminergic systems. with waxing and waning symptoms. sexual. obsessive personality disorder. delusional or schizotypal personality disorders also coexist. 40–30% have recovery with subclinical symptoms. ordering. and avoids it or endures it with great distress. which may be observable or only mental. males are affected twice as much as females. and about 30–35% have recovery but with significant symptoms. or mental rituals. or for blood or injury. recurrent. the most effective pharmacological agents are the SSRIs and benzodiazepines. but become significantly distressing to the patient to warrant treatment only around puberty or early adulthood. which give rise to anxiety. or somatic obsessions. but in men there are more co-morbid disorders. There is strong clinical suggestion that OCD is one of many Obsessive Compulsive spectrum disorders like Asperger’s syndrome. The illness follows a chronic non-remitting course. The obsessive thoughts can be described as aggressive obsessions. Tourette’s disorder. At any given point of time only 20% patients are symptom free. tic disorder. sea etc. Many phobias are associated with co-morbid illnesses like major depressive disorder or other anxiety disorders. hypochondriasis. There is a strong genetic linkage in Obsessive Compulsive Disorders. Compulsions are repetitive behaviours. In treating phobias. kleptomania. Most illnesses start in early childhood. the basal ganglia and the thalamus. whereas in others they change in content but are associated with the same degree of distress. contamination obsessions. dark spaces. Obsessions are intrusive. for situations like closed spaces. rearranging. Obsessive Compulsive Disorder Obsessive compulsive disorders were once considered rare. religious rituals. and shows a lifetime prevalence of 2 to 4% in the population. but obsessive compulsive disorder is the fourth most common mental illness. Tic disorders. Comorbid disorders are frequent. mountains. Familial OCD tends to have earlier onset.
. thoughts or impulses that are difficult to dismiss. the obsessive thoughts remain constant. Women are affected twice as much as men. Lifetime prevalence of phobias is 11–15%. In childhood OCD. Most patients have both obsessions and compulsions. following a strict order or symmetry. Phobias may be for animals or objects. repeating rituals. Compulsive acts may be either checking. religious.

but occurs in response to and extraordinary mental or physical stressor. risperidone etc. Psychotherapeutic intervention is quite helpful in these clinical conditions. In some extreme cases neurosurgical interventions have also been used. irritability.
. The person experiences flashbacks—re-experiencing the trauma through dreams or waking thoughts. and benzodiazepines. helps to fine tune the treatment response. Benzodiazepines. venlafaxine or buspirone. auto accidents. grief. and a state of hyperarousal. riots. from a few days to four weeks. PTSD affects females twice as much as males. and most of them are referred to the psychiatrist. Pharmacological treatment includes SSRIs especially sertraline. Such trauma may be war. Treatment is with newer antidepressants SSRIs. reduced concentration. Post Traumatic Stress Disorder PTSD is found in persons who are exposed to severely traumatic events. and paroxetine. Often augmentation with other drugs like clonazepam. and rape. one must rule out medical conditions which may mimic anxiety. There is a 8% lifetime prevalence in exposed populations. non-specific sleep disturbances. A judicious combination of CBT and pharmacotherapy is effective in most patients. cognitive behaviour therapy and Group therapy. Duration of symptoms is for at least six months. building fires. Treatment consists of supportive therapy and crisis management. especially cognitive behaviour therapy is found to be as effective as pharmacotherapy alone. Insight oriented psychotherapy and Cognitive Behaviour Therapy (CBT) is also helpful. Symptoms appear within a few hours to a month of witnessing the stressor and include social withdrawal. These drugs are used in accordance with the severity of the illness. Acute Stress Disorder This is similar to PTSD. increased muscle tension. To make a diagnosis. lithium. Generalised Anxiety Disorder These are the patients most likely to come to a general practitioner. The significant distress in social or occupational functioning lasts more than a month. Symptoms last a short while. personality disorders or somatoform disorders. encouragement to talk.80
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Treatment is with SSRIs and benzodiazepines. Patients present with symptoms of panic. Benzodiazepines are generally used for a shorter period because of their addictive properties. ‘mind going blank’ etc. disorientation. natural calamities. and shows a persistent avoidance to reminders of the trauma. Behaviour therapy. Treatment is similar to PTSD. aggression. bombings etc. hopelessness and despair. Patients present with excessive tension or apprehension about everyday problems.

fainting or loss of consciousness. Cardiopulmonary symptoms Shortness of breath when not exerting oneself. CLINICAL FEATURES Symptoms from at least two systems must be present continuously for at least two years. Conversion or Pseudoneurological symptoms Amnesia—difficulty swallowing. back pain. Gastrointestinal symptoms Vomiting (other than during pregnancy)—abdominal pain (other than when menstruating).
. SOMATISATION DISORDER (BRIQUET’S SYNDROME) It is primarily characterised by the presence of recurrent and multiple somatic complaints of several years duration for which medical attention has been sought but which was apparently not due to any physical disorder. seizure or convulsion. loss of voice. dizziness. Pain symptoms Pain in extremities. or a strong presumption that the symptoms are linked to psychological factors or conflicts. Symptoms usually begin in the teen years or rarely in the twenties.9
Somatoform Disorders
The essential features of this group of disorders are physical symptoms suggesting physical disorder (hence somatoform) for which there are no demonstrable organic findings or known physiological mechanisms and for which there is positive evidence. Chest pain. bloating. palpitations. nausea. The common somatoform disorders are: I.

Painful menstruation. such process works outside patients awareness/consciousness. Amyloidosis. Female reproductive symptoms judged by the person to occur more frequently or severely than in most women.g. Supportive techniques rather than intensive interpretive psychotherapy is recommended. sexual indifference. symptoms develop abruptly and cease to exist suddenly. SLE. Excessive menstrual bleeding. Differential Diagnosis This disorder has to be differentiated from (i) Physical disorders: Multisystem disorders e. he/she should not be blamed. they should be overlooked. aversive therapies e. Physician should take a non-confrontational approach and patient should not be given any explanation for his/her symptoms at the first meeting. once it becomes clear that symptoms belong to conversion reaction. convulsions. Treatment Non-invassive supportive long-term care of somatisation disorder patients that largely focussed on containing the use of medial resources and avoiding unnecessary surgery and medication use is required. outside consciousness. headache in response to stress. It is more common in females and in those societies where persons emotion are not allowed to be expressed. Therefore in such situations.g. II. irregular menstrual periods. the patient is acting on the repressed emotions to seek attention..g. CONVERSION DISORDER This syndrome is also characterised by the presence of multiple somatic complaints. and not due to any medical disorder.
. According to psychological theories. repressed emotions/wishes are converted into the bodily symptoms and thus the patient is able to seek attention. (ii) Schizophrenia with multiple somatic delusions (iii) Dysthymic disorder (Depressive neurosis) and Generalised anxiety disorder (iv) Panic disorder (v) Other somatoform disorders (vi) Factitious disorder with physical symptoms. Treatment Since. but unlike other somatoform disorders.82
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Sexual symptoms Burning sensation in sexual organs or rectum (other than during intercourse). Importantly. It is also known as Hysteria. Such aversive therapies further damage the already fragmented emotions. in such situations.. ammonia sniffing. impotence. Endocrinopathies etc. putting nasogastric tube should not be used. He should be encouraged to ventilate his feelings. However. patients should be provided with emotional support. Most common presentation is Pseudoneurological symptoms e. Rather.

The disturbance is not due to any other mental disorder. hypochondriasis represents a frequent feature of depression. (iii) Others. Estimates indicate that 85% of all cases of hypochondriasis are of the secondary (depression being the commonest cause) and 15% of a primary nature. Coronary bypass etc. III. tests and medications with addictive potential should be avoided. Most commonly the age at onset is in adolescence. It is also a common response after recuperation from any life-threatening illness (e. Obsessive Compulsive Disorder and Somatisation Disorder. This disorder can occur at any stage of life but begins most frequently in adolescence or early adulthood. If it is secondary to primary illness e.g. The disorder is equally common in men and women. anxiety.). HYPOCHONDRIASIS The unrealistic fear or belief of having a serious disease persists despite medical reassurance and causes impairment in social or occupational functioning. Panic Disorder. IV. The hospitalisations. Treatment is limited to support and avoidance of continuous discussion of the patient’s symptoms. In its secondary forms.g.
. Dysthmic Disorder. Complications are secondary to efforts to obtain medical care. depression. chest and gastrointestinal complaints and musculoskeletal symptoms are noted more frequently. Management It is necessary to exclude organic pathology. although frequently the disorder begins in the 30s for men and the 40s for women. Epidemiology This disorder is common in general medical practice and is more frequently diagnosed in women. (ii) Psychotic disorder. This disorder is commonly seen in general medical practice (ranging from 3 to 10%). in the absence of adequate physical findings and in association with evidence of the etiological role of psychological factors. then by treating this. schizophrenia and early phases of dementia. Headache. SOMATOFORM PAIN DISORDER It is characterised by a clinical picture in which the predominant feature is the complaint of pain. Generalised Anxiety Disorder. Members should be encouraged to be open and discuss their emotions with each other. Differential Diagnosis Hypochondriasis has to be differentiated from: (i) True organic disease. hypochondriacal symptoms will fade away.Somatoform Disorders
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Environment of the family that led to such symptoms should be manipulated.

social and occupational functioning. These symptoms markedly affect patient personal. However.84
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Etiology Severe psychosocial stress is a predisposing factor. Management Complete disappearance of pain through suggestion. somatisation disorder. tense. headaches (Tension headaches). Cognitive behaviour therapy also helps.’ excessive use of analgesics without relief for pain. and investigations Mannkopf’s sign* 10% Localised Often Unusual ± Usually normal Positive Positive 90% Diffuse Rarely Common ± Usually anxious. depressive disorders.)
Differential Diagnosis Organic pain. V. His concern increases if a slight physical defect is also present. BODY DYSMORPHIC DISORDER Patient is preoccupied with an imagined defect in his appearance. requests for surgery and the assumption of an invalid role is common. hypnosis or narcoanalysis suggests psychogenic pain disorder. Clinical Picture The ‘doctor shopping. Treatment SSRI are the mainstay of treatment. schizophrenia. malingering or pain associated with muscle contraction. sad Negative Negative
*(Pressure over or movement of painful part may lead to temporary increase in pulse rate by 10–30/min.
Table 1: Comparison of Physical (Organic) and Psychological Abdominal Pain Abdominal pain Physical Psychological (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) Frequency Pain Pain wakes at night Pain elsewhere in body Vomiting Emotional state Abnormalities on exam. if it reaches delusional level. The use of narcotic analgesics or chronic use of an anxiolytic drug should be avoided.
. than antipsychotics may be given. The individual usually refuses to consider the role of psychological factors in the pain.

A high index of suspicion of malingering should be aroused if any combination of the following is noted: (i) Medico-legal context of presentation e. Symptom relief in malingering is not often obtained by suggestions. hypnosis or intravenous barbiturates as it frequently is in conversion disorder. the person’s being referred by the court to the physician for examination. (iii) Lack of cooperation with the diagnostic evaluation and prescribed treatment regimen. evading criminal prosecution. (iv) The presence of antisocial personality disorder.Somatoform Disorders
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VI. and each medical speciality has tended to develop its own set of guidelines for detection. (ii) Marked discrepancy between the person’s claimed distress or disability and the objective findings.
. MALINGERING It is defined by intentional production of physical or psychological symptoms motivated by identifiable “external incentives” (avoiding work or military obligation. obtaining drugs etc)..g. obtaining financial compensation. The detection of malingering is difficult. In contrast to factitious disorder. there should be an identifiable goal for behaviour other than that of securing the role or parenthood.

this could just be an epitome indicating the proper assessment of the underlying illness. Hence. cerebral haemorrhage. Most commonly the pain occurs due to inflammatory pathologies like vasculitis and infections. place of the study and other criteria for the sample population. It must be kept in mind that only the dura and cranial vessels are pain sensitive. primary headaches predominate and secondary headaches are relatively uncommon. in headache clinics. Largely. Dura is sensitive to stretching and hence. pathologies that increase intracranial pressure suddenly e. while on the other time. Another issue to be remembered in these patients is the nerve supply of the scalp and cranium. Sometimes headache may be a diagnosis in itself. their classification. trauma etc. most of the
.10
Headache in General Practice: What you must know?
Headache is a common complaint that the primary care physician usually come across. This is also the reason why most of the cerebral tumours are painless unless they are large enough to produce stretching. approach to a patient with headache and lastly the treatment of individual headaches. Pathogenesis of Headache Headache is essentially a cerebral pathology and it originates when the sensory nerves in the cranial cavity are irritated. Brain parenchyma is pain insensitive and any damage to the brain itself is painless. anterior half of the head is supplied by sensory branches of trigeminal nerve while posterior half by upper cervical nerves.g. However. Epidemiological studies suggest that headache is widely prevalent in the community and its lifetime prevalence varies from 5% to 83% in different samples depending upon the age. also induce pain. gender. In this chapter we will discuss regarding common causes of headaches. To make the issue more complicated. the pathologies that affect the cranial vessels and dura produce pain.

Causes Cerebral causes Trauma to the head Carebrovascular accidents Intracranial haemorrhage Cerebral Subdural Epidural Sub-arachnoid Cerebral Intracranial infections Meningitis Encephalitis Cerebral abscess vasculitis Giant cell arteritis 4. tension type headache. Primary headache may be termed as functional and are similar to other psychiatric illnesses as available laboratory investigations— biochemical. are supplied by sensory twigs from fifth cranial nerves.
Table 1: Causes of Secondary Headaches S.
. Causes of Pain This knowledge will help us in understanding the causes of headache. eye. These headaches originate in the brain due to activation of central pain perceiving structures. Usually these pathologies affect the facial or the cranial structures. headache with cranial autonomic symptoms e. and list is growing everyday when new headaches are being described. pain from the pathologies of these structures frequently refers to head. Hence. sinuses. hemicranias continua etc. those headaches are included which arise due to some other pathology inside the body. teeth etc. ear. Besides these three major primary headaches. 3. Headache can be classified into two broad categories—primary and secondary. there are a number of other primary headaches such as primary stabbing headache... In the second category.N.Headache in General Practice: What you must know?
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facial structures—oral cavity. Common causes of secondary headaches are described in Table 1. Common types of primary headaches are—migraine and its variants. pathological as well as neuro-radiological do not show any abnormality.N.g. S. nose. medication overuse headache etc. Causes ENT causes ASOM Mastoiditis Acute rhinitis Acute sinusitis Pharyngitis Contact point headache Ophthalmic causes Conjunctivitis Iritis Iridocyclitis Glaucoma Refractory errors Intra-orbital mass
Contd. 1. cluster headache.

Long history of headache that are stereotyped usually points towards presence of primary headaches.N. Causes Hydrocephalus
Psychiatry for General Practitioners
S. patient often have co-morbid illnesses that may be masked. precipitating. location of headache. lasts for the time till they block the interventricular foramen and may be relieved by change in position. Cluster headache usually lasts for hours only. character of headache is very important as tension type headache and most of the other secondary headache may have band-like or heaviness like pain. Classically migraine is pulsating or throbbing type and it was described to increase with each heart beat. Intensity varies among
. average duration of each headache episode. Similarly. radiation and referred pain. sub-arachnoid haemorrhage or the meningitis and glaucoma as well. character. headache may persists until therapy is given. aggravating. it is very important to rule out the secondary headaches. 5. it is prudent the patient should be encouraged to provide as much details as he can. as misdiagnosis may result in spread of primary pathology. You must try to collect details regarding total duration since the patient is suffering from headache. relieving factors and lastly the associated symptoms. Cervical causes Spondylitis Compression fracture PIVD Nerve entrapment 6. duration of headache episode is very important as tension type headache may last from 30 minutes to seven days while usual duration of migraine is from four hours to four days. frequency and intensity of headaches. Frequency may give you a clue regarding progression of disease and help in initiation of proper management. If the patient is unable to provide details adequately. Like any other illness. clinician may guide the interview to find out the relevant information.
Other general causes Malignant hypertension Hypothyroidism Fever
Approach Towards the Patient Even when we know that most of the time headaches are primary. Similarly. Secondary headaches are of variable duration and that depends upon the underlying pathology. If the pathology is severe.
Causes Dental causes Dental infections Periodontal abscess
Idiopathic intracranial hypertension Cranial tumours 2. any change in the character of headache. while headache produced by third ventricular tumours.88 S. whereas recent onset headache or a change in its character may be a guide towards secondary headache.N..g. But care should be taken not to ask leading questions early in the interview for two reasons—this will prejudice the clinician regarding a diagnosis and more importantly. Frequent primary headaches may warrant a prophylactic therapy while infrequent but severe headaches may require just the episodic treatment. Cluster headache is often boring type and the same character is borne by headache due to meningeal irritation e.

Investigations In general. Pain due to glaucoma. It must be noted here that some patients may not have any obvious clinical sign despite gross cerebral pathology. Associated symptoms are most important clue to the diagnosis. Pain in secondary headaches is most severe at the local area though it may refer to different areas depending upon the nerve supply. According to the expert’s opinion this is mandatory in following conditions: 1. phonophobia or photophobia. nasal stuffiness or watering. When patient presents with some neurological deficits 4. Migraine may present with pain in the neck. pain from supratentorail compartment and facial structure is referred to trigeminal territory while pain from the posterior fossa is referred to area supplied by upper cervical roots. haloes. while that of conjunctivitis. relevant laboratory tests must be ordered.
. Although primary headaches often change their character with time. focal neurological deficits. Headache due to increased intracranial tension is usually mild. First onset of headache 2. Fever. then neuroradiological examination is not required. vertigo. rhinitis or sinusitis is mild to mild.Headache in General Practice: What you must know?
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the headaches and headache due to acute SAH is thought to be most severe while tension type headache is mild and rarely moderate. The list is not exhaustive and reader is advised to read the specialised literature for better access to the knowledge. Patient’s preference/assurance scan When secondary headaches are suspected. Migraine is most commonly temporal or retro/intra-orbital and the cluster headache is most prominently orbital. Recent change in character of headache 3. convulsions are seen in cerebral pathologies.. if the physician is sure that headache is benign and is primary headache. eyelid swelling. conjunctival injection. In general.g. ear discharge. Sudden severe intolerable headache 5. change in hearing. Location of headache often provides important clues towards the diagnosis. change in vision. ipsilateral miosis. some people prefer a safer approach and they order neuroradiological examination. Patient should be encouraged to describe these symptoms in detail as they are most important to the diagnosis of secondary headaches. pain on movement of eye may be a clue to eye diseases and gum swelling and problem in bite are manifestations of dental problems. Migraine as well as cluster headache are moderate to severe. dysphagia. Tension type headache usually do not have any associated symptom while migraine often presents with nausea-vomiting. even than this must alert the clinician to seek the presence of another primary or secondary headache. delirium. Cluster headache patients show cranial autonomic symptoms e. red eye. just below the occiput and this may be unilateral. nasal blockade. fever may point to otolaryngological illnesses. iridocyclitis are severe. lacrimation. However.

Its importance must not be underestimated. For secondary headaches. cyproheptadine. For occasional primary headaches. diagnosis must be confirmed by appropriate investigations. zonisamide. remission is impossible. More interested readers may refer to the specialised textbooks of headache.
. Unless these disorders are adequately addressed. which is often refractory to the treatment. topiramate. beta-blockers etc. analgesics. lamotrigine. frequency. avoidance of precipitating and aggravating factors is of paramount importance. But for acute severe attack of migraine and cluster headache. all primary headache patients must be provided due consideration to manage the psychiatric illness both pharmacologically as well as through non-pharmacological means. simple analgesics are preferred. ergots and triptanes can also be used taking appropriate precautions as both these agents are vasopressors and vasoconstrictors. sleep disorders and personality disorders. severity of headache. Hence. mood disorders. corticosteroids. Before starting the therapy. For prophylaxis of headache a number of drugs are available e. Since. In general. primary headaches are chronic disorders. doctors also prescribe these drugs for chronic use which can result in development of medication-overuse headache. ergots and triptanes must not be used more than 4–5 days a month. anxiety disorders. Choice of drug depends upon the physician’s preference. Treatment depends upon the type of headache.g. adverse effects and co-morbid conditions. Acute attack of cluster headache most often responds to the hyperbaric oxygen therapy.90
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Treatment It is not possible to provide the detailed account of the treatment here.g. appropriate therapy must be instituted at the earliest to prevent the spread of illness. It must be remembered that patient frequently misuse these drugs and sometimes. antidepressants. If a patient is complaining of more frequent headache. Here I wish to emphasise the fact that primary headache patients frequently have co-morbid psychiatric illnesses e. So we are providing general guidelines. valproate... prophylactic drugs must be started.

consumption of additive substances etc. cardiac decompensation and other respiratory disorders. Second. In essence. we are ignorant regarding the development of complaints and hence are not able to provide the exact and adequate information. hypertension. is good quality and refreshing.g. cognitive and memory problems. Besides these there are other factors why sleep complaints get unrecognised. one must seek the advice from the physician when he is not able to get the refreshing sleep. data regarding adolescent population of a metropolitan city is available which shows
. Why is he not having refreshing sleep? This is the key question that every sleep-specialist looks for whenever you approach him for these complaints. headache. mood regulation. Third. most of us want the readymade therapy (sleeping pills) and usually do not help the physician to go into details. stress.11
Problems of Sleep
Many of us at different times in our life have experienced that we are not able to sleep properly. Though the issue appears trivial. Quality of sleep also varies and is dependent upon the corporal and environmental factors.g. Since quality of sleep differs from person to person and is dependent upon one’s expectations regarding sleep. Among all these factors. hence ‘refreshing’ sleep is the surrogate marker. diabetes etc. Fourth. we are not courageous enough to accept the fact that we are doing something wrong with our body and hence try to hide those facts e. Proper sleep is considered one that is adequate in duration. work performance. refreshing sleep is one that needs emphasis as duration is individualised and cannot be generalised beyond a certain limit. Refreshing means that one is able to work in best of his capacity after leaving the bed provided he is not having any other problem. obstructive sleep apnea.g. a number of people (including physicians) are not aware that non-refreshing sleep is sometimes the only complaint of other serious underlying disorders e. How common is this problem? Though at present we do not have any data regarding sleep problems in Indian adult population. periodic limb movement disorder. probably getting a good quality sleep is very low in our priority list despite the fact that non-refreshing sleep may lead to other pathologies e. not following sleep hygiene. but most of the times it is very difficult to answer owing to multiple reasons. First. depression.

g. lying wake up in the bed waiting for the sleep etc. difficulty breathing in lying down situation. substance dependence e. Precipitating factors are those that are under our control and which when present. reading books. your heart beats faster. These situations usually induce episodic problems but in presence of perpetuating factors. poor sleeping place. bright lighting etc. From medical point of view. Researchers have noticed that insomnia patients keep worrying about their sleepproblem and its effect on their functioning. A good therapist tries to curtail the impact of modifiable factors but it cannot be done without cooperation of the patient and sometimes co-sleeper. extremes of temperature. situational. However. precipitating and perpetuating. Is this problem serious? Seriousness of any problem cannot always be judged by the overtly conspicuous lifethreatening issues or physical debility produced. What causes this problem? There are a number of reasons that contribute to the development of non-refreshing sleep. we divide these factors into three classes—predisposing. Secondly. heavy intake of caffeine during waking period. alcohol. sleeping pills. sleeping pills.g. When we see it at large scale. your arousal level e. psychiatric disorders e.g. overcrowded room. watching television. Medical disorders e. medications etc. anxiety etc. changing sleep schedule. certain brain tumours etc. The causative factors are not mutually exclusive and most of the times they are present together to compound the diagnostic and therapeutic exercises. frequently changing work shifts or time zones. pills are not the answer always and you need to help your treating physician to reach a conclusion and address underlying issues. you are easily disturbed by the trivial emotional stimuli. stress.g. higher metabolic rates.g. cocaine etc. performing activities in the bed for which it is not meant e. your body clock which needs less sleep. Environmental factors e. Predisposing factors are those that you are born with and most of the times you may not have control over them e. as mentioned above are included in this group. their impact is more on persons with predisposing factors. recent research has contradicted this issue and found these factors to be the result rather than cause of insomnia. medical or psychiatric illnesses.g. poor ventilation.. lead to chronic problem.g. may cause or contribute to the illness. As we have mentioned. negative conditioning with the sleeping environment is an important issue. remember it. their bed and bedroom becomes associated with awakening than sleeping (conditioning). Perpetuating factors include cognitive and behavioural factors. strange surroundings etc. Insomnia sufferers in absence of proper guidance and quick relief adopt some antagonistic behaviours e.g.92
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that majority of adolescents are sleeping one hour less than required duration in the respective age and it is culminating in their school performance. noisy surroundings. these patients keep on lying on their bed awake in the night and slowly.. increase the chances of poor sleep in an any person. may cause non-refreshing sleep. hence further increasing the stress and consequent insomnia. loss of working
. cannabis. primary insomnia. and you keeps on thinking a lot on trivial issues. pain anywhere in the body. depression. Western data show that at a given time around 15% persons in a given community suffer from insomnia. mosquitoes. however. Hence. All environmental.

The evaluation starts with the information regarding your complaints and includes complete physical examination. psychiatric evaluation and sometimes laboratory investigations. Sometimes. Sleep promoting behaviours are also called. How to combat it? Fighting with insomnia is the joint work of physician and patient. at least in metropolitan cities. very cold or hot. Always remember. mood regulation.Problems of Sleep
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hours. resultant loss of money gives better idea regarding gravity of any issue. but you must talk to him more about your queries and fears at that time only to help yourself. headache. what your physician suggests may not appeal to you. pills are usually not the answer to chronic insomnia and minute change in environmental. but situation is not better than that mentioned above. In addition. poor work capacity. good sleep hygiene and they are helpful not only therapy of the insomnia but also its prevention. It is estimated that in US around 2 billion dollars are spent every year on sleeping pills and indirect cost from above mentioned reasons when added. the figure reaches more than 100 billion US$ per annum. Though we do not have Indian data at present. and their management. work performance. psychiatric illness and sometimes sleeping pills. and increased health related expenditure and in turn. Multiple therapeutic options are available and choice of any of these depends upon the physician’s preference and his judgement. We will not go into details of all these. stress. noisy etc. hypertension. We will not discuss these in detail as they are out of scope for this book but will discuss sleep promoting behaviours. systemic examination. cognitive and behavioural factors may be more useful. Both must be willing and dedicated to diagnose the underlying problem and treat it. These are mentioned in table 1.
Table 1: Do’s
• • • • • •
Don’ts
• • • • • • • •
Maintain a regular sleep-wake schedule Should take adequate amount of food before going to bed Indulge in physical exercises during the day Take balanced diet Go to bed only when sleepy Always leave the bed at the same time in the morning
Do not take caffeinated beverages/coffee/tea before four hours of bed Do not indulge in heavy exercise before going to bed Avoid daytime naps Surrounding environment should not be crowded. Therapy of insomnia includes management of medical disorders. we wish to again emphasise upon the cost of insufficient sleep borne by you in terms of cognitive and memory problems. diabetes etc. Avoid alcohol close to bedtime Avoid doing your work in the bed Should not be hungry or do not eat too much in the dinner Do not watch TV while in bed
.

Sleep-restriction therapy This therapy increases the internal sleep pressure and thus helps in achieving the normal sleep wake cycle. In this therapy. to name a few: benzodiazepines. This therapy has proven very effective when instituted in the right candidates and does not include any kind of pill-popping. many a times bed becomes negatively associated with the sleep and thus person remains wake up while in bed. Whether a drug should be given or not. When you are able to sleep for approximately 90% of your time in bed (determined by sleep diaries). Hence. nonbenzodiazepine hypnotics. (c) Indulge in relaxing exercises while out of bed and lastly. during which the anxiety and sleep complaints may actually increase.94
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Stimulus control therapy As we have discussed above. patient is ask to follow simple instructions as follows: (a) Use the bed for sleeping only. In coordination with the patient. Hence. leading to mismanagement and long-term deterioration of underlying problem. unfortunately these are prescribed indiscriminately by some medical persons. Stimulus control therapy aims at deconditioning of negative cues and reconditioning of healthy cues. there is no point in continuing them beyond that period. go to bed. depends upon the condition of the patient and diagnosis.
. this requires dedication from the patient side. many of these drugs are available over the counter and sometimes. However. which is the right drug. though in the initial part. For example. We wish to emphasise here that the benzodispines at least. time in bed is increased gradually. patient’s bed time is reduced to the amount of time spent in sleep. Pharmacological management There are many drugs available that can induce sleep. but picking up the right patient is probably the most important part of therapy. these beliefs are identified and then challenged gradually. which is decided by the sleep-diary. Since. In this therapy. some antidepressants. when feels sleepy. it may rather provoke the anxiety and may interfere with sleep. they are overused and sometimes in the wrong patient. if you spend 8 hours in bed and sleep for five hours only. are not effective pharmacologically after 2–3 weeks of continuous use. and if yes. (b) Leave the bed when not able to sleep. your time in bed is reduced to 5 hours only. you must be ready to pay initial price for long-term benefits. Cognitive behaviour therapy This therapy addresses the unrealistic beliefs and attitudes regarding sleep and sleep problems. This therapy consists of simple instructions. centrally acting antihistaminics etc. This is very effective method. and shows its effect in at least 1–2 weeks. This therapy can be combined with any of the above mentioned methods to achieve total control over the situation.

But. The biological purpose of stress is to prepare us fight real. an event and the consequences of an event. physical danger. which causes the body defenses to become alert about the danger or stress. There are two main types of stress experienced by humans. For the sake of simple understanding . either chronic or that which is emergencyinduced. Stress when pathological. it produces a physiological response called the “fight or flight” reaction. Stress is actually a good thing to have. causes lot of physical and mental health problems. workers. Any change in the environment demands some coping. consequently. Etiology of stress The stress activate the pituitary adrenal axis and lead to what is known as the General Adaptation Syndrome (given by Hens Seyle in 1945). The chronic type of stress can be particularly harmful to the brain because of hormones and chemicals referred to as glucocorticoids or GCs. When the body experiences a rush of adrenaline which is accompanied by stress.
. or a commercial pilot to a sales executives.12
Stress and its Management
Stress is what everybody experiences in daily life. and little stress helps us adapt. affects the health of the individuals. It consists of: (i) Alarm reaction (shock). which helps us to fight the danger or flee it. Stress refers both to a subject. and a predicate. beyond some point stress becomes distress basically individual’s response to fight/flight a situation. When the danger alarm is turned on. starting from an artist to a surgeon. we take the example of stress as a false alarm in the brain which is activated in response to a danger signal. (ii) Resistance (adaptation to stress) which is characterised by secretion of hormones or defensive chemicals to contain stress. Stress at work is a relatively new phenomenon of modern lifestyles. a portion of our brain called the adrenal cortex begins to release these GCs which are useful for dealing with the emergency-type of stressors. It covers all professions. Stress was coined by Hens Seyle.

syncope. sympathetic and parasympathetic nervous system. 2. neurodermatitis. social support). 3. all neuroregulatory mechanisms undergo functional changes that depress the body’s homeostatic mechanisms. Raynaud’s disease. connective tissue diseases like systemic lupus erythematosus. hypertension. and a variety of support networks as modifying factors for the occurrence of mental illness. George Engel postulated that in the stressed state. angioedema. Stress and psychiatric disorders The expression of mental illnesses was affected by life circumstances. Major depressive disorder – Several life events predict onset of major depressive disorder. Small amounts of stress enhance immune function. Neuromessengers include such hormones cortisol. Anxiety disorders – Panic disorders has its onset with stressful life events.g. Post traumatic stress disorder and acute stress reaction had their onset following traumatic events such as violent assaults or serious accidents. adrenal medulla. stressful life events as initiating or exacerbating factors. ulcerative colitis. Stress plays a role in a number of psychiatric disorders. coronary spasms. premorbid personality) and extrinsic factors (e. epinephrine. osteoarthritis. Stress and medical professionals 1. hyperventilation syndrome. asthma. metabolic and endocrine disorders. headaches. inflammatory bowel diseases like Crohn’s disease. hypothalamus. Individual’s response to stress is modified by a number of intrinsic factors (e. genetic vulnerability. lack of communication skills. Do doctors experience stress? If so. 1. leaving the body vulnerable to infection and other disorders.
(iii)
. 4. rheumatoid arthritis. peptic ulcer disease. obesity. excess stress impairs it. Neurophysiological pathways that mediate stress reactions are cerebral cortex. dealing with emotions—constant struggle of life and death. uriticaria. limbic system. Meyer proposed the biopsychosocial model.g. Stress and non-psychiatric disorders Stress plays an important role as a triggering factor or as an exacerbating factor in a number of non-psychiatric disorders like angina. Interpersonal conflict or serious illness has been shown to trigger the onset of panic disorder in susceptible individual. increased expectations of clients. thyroxine. Chronic interpersonal stress is an important risk factor for relapse in Schizophrenia. arrhythmias. The model incorporated individual temperamental and experiential characteristics such as potential vulnerability (or resiliency) factors. etc. Several studies had shown that high degree of expressed emotions cause more relapse than those who live in families with low expressed emotions. irritable bowel syndrome.96
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Exhaustion (resistance to prolonged stress cannot be maintained). what could be the contributing factors? Long working hours. which results in failure of body defenses when stress in severe and prolonged.

you record information about the stresses you are experiencing. relaxation training. on a regular basis. and • How you react to stress. mental. and IT consultants appeared to be victims. • Also make an entry in your diary after each incident that is stressful enough for you to feel that it is significant. conscientiousness. Burn out syndrome is an illness seen among the high achieving intellectual workers like teachers. self defeating beliefs. poor social support often lead to burn out. Long working hours. and emotional exhaustion. and lack of support from one’s partner and colleagues. appeared to be predictive of stress. doctors. time management. increased work pressures. They also give you an important insight into how you react to stress. increased duration of training. Stress Diaries help you to understand: • The causes of stress in more detail. so that you can analyse these stresses and then manage them. a scarcity of female mentors in leadership positions. Unique challenges facing female residents include the existence of gender bias and sexual harassment. cognitive restructuring. and lack of empathy. and problem solving. and whether your reactions are appropriate and useful. no vacations. high degree of professional commitment. uneasiness. poor quality of training. stress relating to the work-home interference increased during their early career. The clinical criteria includes physical. • The levels of stress at which you operate most effectively. What must they do as good doctor? Self defeating beliefs – Very often. Self Observation Stress Diaries are important for understanding the causes of short-term stress in your life.
. doctors blame themselves for difficulties. Burn out was classed as an illness affecting those with low self reliance and depressive personality types. The idea behind Stress Diaries is that. Maladaptive coping style in which the individual perceive their environment as stressful. Some studies found that subjective ratings of high pressure and insufficient sleep are associated with poor job performance in medical residents.Stress and its Management
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2. Is medical profession more stressful? Low salary. • They establish a pattern that you can analyse to extract the information that you need. primarily of the female gender. 3. and help you to identify the level of stress at which you prefer to operate. and work/family conflicts. Neurotic traits. STRESS MANAGEMENT There are five basic skills that form core of all stress management programmes: self observation.

• How well you handled the event: Did your reaction help solve the problem. with the most frequent stresses at the top of the list. • How effectively you are working now (a subjective assessment. again on a subjective scale of 0 to 10. • Finally. look at how you felt when you were under stress. you should fully understand what the most important and frequent sources of stress are in your life. write down the mood you are feeling. As before. headache. “butterflies in your stomach”. look at your assessments of their underlying causes. look at the different stresses you experienced during the time you kept your diary. and think about how you felt. using a subjective assessment on a scale of –10 (the most unhappy you have ever been) to +10 (the happiest you have been). while a 10 would show the greatest effectiveness you have ever achieved. look through your diary at the situations that cause you stress. prepare a second list with the most unpleasant stresses at the top of the list and the least unpleasant at the bottom. and could improve your stress management skills? If so. • Next. on a scale of 0 to 10. • The fundamental cause of the stress (being as honest and objective as possible). 0 here would be the most relaxed you have ever been. • Having analysed your diary. sweaty palms. You may also want to note: • How stressed you feel now. As well as this.). and your appraisal of how well you handled the stressful event. Do these show you areas where you handled stress poorly. You should appreciate the levels of stress
. while 10 would show the greatest stress you have ever experienced.g. anger. • The most recent stressful event you have experienced. List the types of stress that you experienced by frequency. etc. Look at how it affected your happiness and your effectiveness. • How happy you feel now. • Working through the stresses. or did it inflame it? Analyse the diary at the end of this period.98
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Every time you make an entry. Analysing the Diary Analyse the diary in the following ways: • First. those at the top of each list are the most important for you to learn to control. • Looking at your lists of stresses. • The symptom you felt (e. List these. raised pulse rate. • Next. record the following information: • The date and time of the entry. understand how you behaved. list these. A 0 here would show complete ineffectiveness.

music therapy. acupuncture. and keep your workload under control. and what constitutes success within it. and several techniques have been found to be of considerable use in stress management. massaging etc. When individuals learn to relax. A sense of humour also allows us to perceive and appreciate the incongruities of life and provides moments of delight. you can focus on these activities and minimise work on other tasks as much as possible. You should also know the sort of situations that cause you stress so that you can prepare for them and manage them well. By understanding the priorities in your job. this should be a trigger for you to use appropriate stress management techniques. aerobic exercises. The alternative is to work more intelligently. The emotions we experience directly affect our immune system. beliefs. acupressure. Adopting a humorous view towards life’s situations can take the edge off everyday stressors. you should now understand how you react to stress. by focusing on the things that are important for job success and reducing the time we spend on low priority tasks. relaxation skills like Jacobson are found to be quite effective. their overall muscle tension is reduced. breathing exercises. The positive emotions can create neurochemical changes that buffer the immunosuppressive effects of stress.Stress and its Management
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•
at which you are happiest. and the symptoms that you show when you are stressed. Relaxation training Relaxation skills are very helpful in managing stress. Individuals who are able to relax are also more likely to be able to think more rationally and be able to restructure negative cognitions when faced with stressful events. Cognitive behavioural therapy makes the individuals aware of and to change their maladaptive thoughts.” We must learn to focus ourselves on most urgent and most important areas.“Time is money. Finally.
. This helps you get the greatest return from the work you do. and expectations. Job analysis is the first step in doing this. Not being too serious or in a constant alert mode helps to maintain the equanimity of mind and promote clear thinking. laughter.
Cognitive restructuring Cognition plays a key role in the stress and coping process. Being able to laugh stress away is the smartest way to ward off its effects. as is their overall level of automatic arousal. Other alternative measures Yoga. When you experience these symptoms in the future. As well as this. TIME MANAGEMENT The old saying goes.

Acknowledge your own humanity: remember that you have a right to pleasure and a right to relaxation. • Ensure that you are following a healthy lifestyle: 1. 18. Evaluating alternatives and finding the best solution. Some simple practices can help minimise stress • Sit straight and comfortably on your seat. family and even counselling in reducing stress. It will relax your nerves and muscles.
. Problem identification 2. • Evaluate the demands placed on you and see how they fit in with your goals. 3. Involve other people in a supportive role. • Identify stressors in your life. balanced diet—bad diet can make you ill or feel bad. Get adequate sleep and rest to maintain your energy levels. Try to recognise your spiritual needs that may have been buried under the mires of worldly pursuits. • Relax and count backwards (20. and try breathing exercises. Generating alternatives 3. the suggestions below can help you correct the situation: • Re-evaluate your goals and prioritise them. Limit your caffeine and alcohol intake. or family. Get the support of your friends.100
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Problem Solving Problem solving involves few basic steps 1. 16.) Are You in Danger of Burning Out? If you feel that you are in danger of burning out. 15…. • Learn stress management skills. 17. • Develop alternative activities such as a relaxing hobby to take your mind off problems. 2. • Identify your ability to comfortably meet these demands. Ensure that you are eating a healthy. become more unapproachable and less sympathetic. 19. such as work. • If people demand too much emotional energy.

For example. even though they have psychological consequences. since a disorder in the earlier stage can precipitate/aggravate or mimic problem of subsequent stage.g. Various sexual disorder are classified according to stages of response cycle in Table 2. This differentiation is important in understanding of pathology as well as the therapy. In such case investigations or treatment of erectile disorder will result in unnecessary investigations or therapeutic trials. The sexual disorders can be classified according to stage in which they occur. physicians.
. Table 1 summarises various phases. The name for this diagnostic class emphasises that psychological factors are assumed to be of major etiologic significance in the development of the disorder. gynecologists or so-called sexologists. patient may present with complaints of erectile dysfunction while he is actually suffering from hypoactive sexual desire disorder. psychiatrists. which are found in almost all people in the sequential manner. Erectile Dysfunction (Table 3) and Dhat Syndrome • Paraphilias • Other sexual disorders: Gender identity disorder and homosexuality Normal human sexual response cycle can be divided into various phases. It is important for all clinicians to take a detailed sexual history from their patients and have an understanding of the diagnosis and management of the sexual disorders. The topics which will be discussed in this chapter are as follows: • Normal human sexual response cycle (Table 1) • Various disorders according to individual phase (Table 2) and their management e. sequentially starting from stage 1. are not discussed in this chapter. Disorders of sexual functioning that are caused exclusively by organic factors. They may present to venereologists.13
Psychosexual Disorders
Individuals with sexual disorders are likely to be encountered by clinicians in all disciplines. surgeons.. While collecting the information/history it is important to rule out dysfunction in every stage.

which starts with physical stimulation and/or by appetitive phase. The duration of this phase is highly variable and may last for several minutes (or longer). • Elevation and enlargement of testes. which starts with physical stimulation and/or by appetitive phase. • Elevation of testes with scrotal sac. Appetitive Phase This is the phase which occurs before the actual sexual response cycle. 3.
. • Erection of clitoris. 2. due to vascocongestion of corpus cavernoa. It is often difficult to differentiate the plateau phase from the excitement phase. 2. at the height of excitement. Plateau Phase This is an intermediate phase just before actual orgasm. Excitement Phase This is the first true phase of the sexual response cycle. Appetitive Phase This is the phase which occurs before the actual sexual response cycle. The duration of this phase is highly variable and may last for several minutes (or longer). • Erection of nipples (in most women). • Dew drops on gland penis (2–3 drops of mucoid fluid with spermatozoa).. This consists of sexual fantasies and a desire to have sexual activity. with lengthening and ballooning of vagina.
Contd. Excitement Phase This is the first true phase of the sexual response cycle. This consists of sexual fantasies and a desire to have sexual activity.102
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Table 1: Normal Human Sexual Response Cycle A normal human sexual response cycle can be divided into five phases. • Autonomic hyperactivity. The following important changes occur during this phase: • Sexual flush (inconsistent). The duration of this phase may last from half to several minutes. • Erection and engorgement of penis to full size. 3. The duration of this phase may last from half to several minutes. • Development of orgasmic platform in the lower 1/3rd of vagina. • Autonomic hyperactivity. Males 1.. The major changes during this phase are listed below: • Lubrication of vagina by a transudate. The following important changes occur during this phase: • Sexual flush (inconsistent). • Retraction of clitoris behind the pupuce. • Enlargement of breasts and labia minora. The major changes during this phase are listed below: • Penile erection. at the height of excitement. Females 1. It is often difficult to differentiate the plateau phase from the excitement phase. increased vaginal transudate. • Thickening of labia minora. Plateau Phase This is an intermediate phase just before actual orgasm.

Females 4. The duration of this phase may last from 3–15 seconds. • Disappearance of sexual flush followed by fine perspiration. decreases with age). • Autonomic excitement becomes marked in this phase. • Gradual decrease in vasocongestion from sexual organs and rest of the body. • Ejaculatory spurt (30–60 cm. The duration of this phase may last from 3–15 seconds. and seminal vesicles. cervix and uterus. at about 0. • Disappearance of sexual flush followed by fine perspiration.8 sec. Increase in systolic and diastolic BP occur. • While there is usually no refractory period in females. The important changes are as follows: 14–10 contractions of penile urethra. and rhythmic contractions of pelvic reproductive organs. The important changes are as follows: • 3–15 contractions of lower 1/3rd of vagina. 5. Doubling of pulse rate and respiratory rate. at about 0. Doubling of pulse rate and respiratory rate. intervals.
5. No contractions occur in clitoris. increase in systolic and diastolic BP occur. • Autonomic excitement becomes marked in this phase. Resolution Phase This phase is characterised by the following common features in both sexes: • A general sense of relaxation and wellbeing. • Contractions of external and internal sphincters. • Contractions of external and internal sphincters. and rhythmic contractions of pelvic reproductive organs.8 sec.Psychosexual Disorders
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Males 4.
. after the slight clouding of consciousness during the orgasmic phase. Orgasmic Phase This is the phase with a peak of sexual excitement followed by a release of sexual tension. intervals. vas. prostate. and 10–40 mm. Resolution Phase This phase is characterised by the following common features in both sexes: • A general sense of relaxation and wellbeing. • Ejaculatory inevitability precedes orgasm. Orgasmic Phase This is the phase with a peak of sexual excitement followed by a release of sexual tension. • Gradual decrease in vasocongestion from sexual organs and rest of the body. • Refractory period for further orgasm in males varies from few minutes to many hours. after the slight clouding of consciousness during the orgasmic phase. and 10–40 mm. The duration of this phase may last from 3–15 seconds.

valour. The Sanskrit word ‘Dhatu’. the wider and colloquial use today is synonymous with semen. spermatorrhoea. the disturbances in the ‘Dhatus’ have been elucidated in the Charak Samhita (another ancient treatise of Indian medicine). Myanmar.g. ‘Shukra’ is a term which more specifically refers to the sperm content of seminal fluid and is derived from the Sanskrit word ‘shuch’ which literally means the ‘essence’ or fire or glow.
Resolution Others not Related to Sexual Phase Sexual Pain Disorders Others
Dhat Syndrome It is a true culture bound sex neurosis quite common in the natives of the Indian subcontinent (e. according to Susruta Samhita (an ancient treatise of Indian medicine). III. II. It describes a disorder resembling Dhat syndrome by the name ‘Shukrameha’ in which there is passage of semen in the urine. Though purists still use the term ‘Dhatu’ to connote ‘Paddarth’ or basic material or metal. Thus. Genital pain during masturbation. II. strength. Sri Lanka. B. female analogue of premature ejaculation. means the elixir which constitutes the body and has given rise to the term ‘Dhat’. In India. I. premarital or extramarital relations. the keeping of one’s seed is life. Similar syndromes exist in China (Shenkui) and Taiwan (Shen-k’uei). power or that which generates power and greatness. Pakistan.104
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Table 2: The Various Psychosexual Dysfunctions can be classified as
A.
IV . Bangladesh. I. those living in India. etc. According to Shiva Samhita (an epic in Hindu Mythology) the falling of seed (sperm) leads towards death. is the most harmful thing
. Sexual Response Phase Appetitive Excitement Orgasm Related Dysfunctions * Hypoactive Sexual Desire Disorder * Sexual Aversion Disorder * Female Sexual Arousal Disorder * Male Erectile Disorder * Female Orgasmic Disorder (Anorgasmia) * Male Orgasmic Disorder (Retarded Ejaculation) * Premature Ejaculation * No Dysfunctions Reported Related Dysfunctions * Vaginismus (female) * Dyspareunia (male and female) * Orgasmic anhedonia. nocturnal emission. semen is also known by the name ‘Virya’ derived from a Sanskrit word meaning bravery. Nepal. Hence with all his power should a man hold his seed. the belief that the loss of semen from the body in any manner—masturbation. History. Dhat syndrome can be properly conceptualised in its entirely with an adequate understanding of the word ‘Dhat’ and the certain ancient Indian beliefs about it.). According to Susruta Samhita as well as Ayurveda (the Indian system of medicine).

over inhibition. Stroke or Alzheimer’s disease Spinal cord injury Radical pelvic surgery Diabetic neuropathy Pelvic injury Hypogonadism Hyperprolactinemia Atheroscerlosis hypertension Diabetes mellitus Trauma Peyronie’s disease Antihypertensive and antidepressant drugs Antiandrogens alcohol abuse Cigarette smoking Old age Diabetes mellitus Chronic renal failure Coronary heart disease Pathophysiology Loss of libido. resulting in neural and vascular dysfunction
Caused by other systemic diseases and ageing
The belief of so-called precious and life preserving property of semen is deeply ingrained in the Indian culture. Commonly Encountered Disorders (A) Male Erectile Dysfunction is one of the commonest causes for seeking help. Sometimes. Various causes can be classified as follows (Table 3). Decreased libido. depression etc.N. this belief is perpetuated by the friends or relatives. Alcoholic neuropathy. or impaired nitric oxide release Failure to initiate nerve Impulse or interrupted neural transmission
Neurogenic
Hormonal Vasculogenic (arterial or cavernosal)
Loss of libido and inadequate nitric oxide release Inadequate arterial flow or impaired veno-occlusion
Drug induced
Central suppression.Psychosexual Disorders
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that can possibly happen and its preservation guarantees health and longevity. ‘Dhat Syndrome’ a term first used by N. The quacks and lay experts reinforce this traditional belief and thrive on the ignorance of the common man. relationship problems. Table 3: Classification and Common Causes of Erectile Dysfunction
Category of erectile dysfunction Psychogenic Common causes Performance anxiety. Wig in 1960. Psychological stress. Sometimes an overvalued idea that the semen has become foul smelling and less viscous in consistency may be present. is a commonly recognised clinical entity in Indian culture. Vascular insufficiency Usually multifactorial.
. who had suffered from this syndrome.

Sometimes an overvalued idea that the semen has become foul-smelling or less viscous in consistency may be present. Physical Illnesses. The excessive intake of fluids and acidification of urine (by prescribing ascorbic acid) may help in removing the turbidity due to concentrated or alkaline urine. The patients believed Dhat as semen.g. anxiety.. The main treatment of Dhat syndrome is education.) and spermatorrhoea which may produce turbidity in urine. The exact prevalence of this disorder is not known. 1989).108
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Epidemiology. counselling and reassurance. sad mood. religion etc. of average or low socio-economic status. the knowledge and attitudes of patients toward Dhat syndrome were studied. The use of antianxiety or antidepressant medication is required when the symptoms of anxiety or depression are prominent. The patient is typically a young male.’ believed to be semen by the patient. but they should be used for a few weeks only and the use of dependence producing drugs should be avoided. drugs intake (antacids. if present needs appropriate simultaneous attention. etc. etc). psychological symptoms (like guilt. weakness. The patient perceives the slightest turbidity in urine with unbelievable perturbance. tonics. loss of appetite. Psychological Disorders.g.. more likely to be married or recently married. comes from a rural or semiurban area and belongs to a family with conservative attitudes towards sex. sugar. sexually transmitted diseases. The passage of a whitish discharge with urine is described as ‘Dhat. etc. A majority of patients believed masturbation or excessive sex as the major cause of Dhat syndrome and expressed the belief that it might lead to physical and mental weakness and require some medication.) may help in ruling out physical or psychological problems. although there is no objective evidence to it. Differential Diagnosis i. VDRL etc. lack of concentration and memory etc. Dhat has been reported as the whitish discharge which passes along or before the passage of urine. In a study (Bhatia et al. The careful detailed history and routine investigations (urine examination. This is usually related to the presence of oxalate and/or phosphate crystals which are present in a high concentration in the alkaline urine of the average Indian consuming vegetarian diet. as they themselves can produce turbidity in urine. premature ejaculation). The individuals with Dhat syndrome present with vague somatic symptoms (like fatigue. somatoform disorder etc. Scientifically. which the patient attributes to the passing of semen (Dhat) in urine as a direct consequence of his excessive indulgence is masturbation or sexual intercourse. ii. The other factors like literacy. diabetes mellitus.). concentrated urine or not known. sexual dysfunctions (impotence.. labourer or farmer by occupation.
. The so-called ‘tonic’ or injectable anabolic steroids should be avoided. Dhat syndrome needs differentiation from a number of physical diseases (e.. Anxiety states. are unimportant.. The primary psychiatric illnesses e. student.) and at times. It constitutes about 30 to 60 per cent of patients presenting with a psychosexual problem. depression. Clinical Picture.

an avid interest in sports and rough-and-tumble play and a lack of
. i. Other disorders are listed in Table 6. Gender Identity Disorders Disturbances in gender identity is rare and should not be confused with the far more common phenomena of feelings of inadequacy in fulfilling the expectations associated with one’s gender role e. which may lead to persistent requests for sex reassignment by surgical or hormonal means.. Transsexualism (Gender Dysphoria Syndrome) Individuals with this disorder usually complain that they are uncomfortable wearing the clothes of their own anatomic sex. Paraphilias (Sexual Deviations) The paraphilia disorders are characterised by repetitive or preferred sexual fantasies or acts that involve non-human objects or non-sonsenting partners. However. They may have a preference for dressing in girl’s or women’s clothes. However. Often they choose to engage in activities that in our culture tend to be associated with the other sex. In rare cases. dress and mannerisms are those of the other sex. Outcome. Frequently there is considerable anxiety and depression which the individual may attribute to inability to live in the role of the desired sex.) need appropriate intervention. a boy with this disorder claims that his penis or testes are disgusting or will disappear. Dolls are often the favourite toy. a small number of patients. Girls with this disorder regularly have male peer groups. To varying degrees. The outcome of ‘pure’ Dhat syndrome is good. Table 7 summarises various paraphilias. and electrolysis a few males with the disorder will appear relatively indistinguishable from members of the other sex. Gender Identity Disorder of Childhood Boys with this disorder invariably are preoccupied with female stereotypical activities.g. the anatomic sex of most males and females with the disorder is from members of the other sex. These individuals often find their genitals repugnant. However.Psychosexual Disorders
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The associated psychosexual dysfunctions (impotence. who fail to receive what they desire. With cross dressing. Most of the patients recover completely. Generally there is moderate to severe coexisting personality disturbance. frequently this discomfort leads to cross-dressing (dressing in clothes of the other sex). may drop out and indulge in “Doctor-shopping”. the behaviour. and girls are regularly the preferred playmates. the anatomic sex of most males and females with the disorder is apparent to the alert observer. They often have a compelling desire to participate in the games and pastimes of girls. ii. premature ejaculation etc. or may select such items from available material when genuine articles are unavailable (the crossdressing never causes sexual excitement). an individual who perceives himself or herself as being sexually unattractive yet experiences himself or herself unambiguously as a man or woman in accordance with his or her anatomic sex. hormonal treatment.

. Isolated Sexual Acts with children may be precipitated by marital discord. Transexualism: No sexual excitement with crossand persistent wish to be rid of one’s own genitals.Table 7: Some Characteristics of Paraphilias (Sexual Deviations)
Diagnostic criteria (Repeated. It is not diagnosed when limited to articles of female clothing. alcohol intoxication or Schizophrenia only isolated acts are there. Contd. preferred or exclusive method of achieving sexual excitement by — Fetishism Use of non-living objects (fetishes) the fetishes are not limited to articles of female clothing or used for purpose of sexual stimulation.. Recurrent and persistent cross-dressing by a heterosexual male for purpose of sexual excitement. Age at onset Course Differential diagnosis
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Adolescence or childhood
Chronic
Non pathological sexual experimentation (Stimulus is neither preferred nor required) Transvestism. Sexual arousal limited to articles female clothing used in cross-dressing.
Psychiatry for General Practitioners
Transvestism
Childhood or early adolescence
Chronic may develop into transexualism Chronic
Zoophilia
Act of fantasy of engaging in sexual activity with animals. Female impersonators act does not cause sexual arousal or interference does not cause frustration Fetishism. Non pathological sexual activity with animals when suitable human partners are not available.
No information
Pedophilia
Adulthood or middle age
Unknown (Chronic)
. Exhibitionism Exposure may be a child but the act is not prelude to further sexual activity Sexual Sadism. Mental retardation Organic Personality Syndrome. rental loss or intense loneliness. Act of fantasy of engaging in sexual activity with pre-pubertal children.

Psychosexual Disorders
Masochism
International participation Variable in an activity in which one (early adulthood) is humiliated. Pedophilia when exposure occurs. Masochistic fantasies Sexual masochism is diagnosed if the individual engages in acts Masochistic Personality traits.
Pre-adolescence to middle age (commonest mid-puberty)
Chronic
Repeated exposure without experiencing sexual excitement. beaten or otherwise made to suffer. A rapist not motivated by the prospect of inflicting suffering and may even lose sexual desire as a consequence. bound.Table 7: Some Characteristics of Paraphilias (Sexual Deviations) (Contd. They are not associated with sexual excitement. Rape or other sexual assault.
Voyeurism
Early adulthood
Chronic
Normal sexual activity It is not with an unsuspecting partner and is usually a prelude to further sexual activity Watching pornography. Intentional infliction of psychological or physical suffering on a non-consenting partner. it is a prelude to sexual activity with child.)
Diagnostic criteria Age at onset Course Differential diagnosis
Exhibitionism
Acts of exposing the genitals to an unsuspecting stranger with no attempt at further sexual activity with the stranger. in sexual activity and no sexual activity with the observed people is sought. The people being observed are willingly in view.. Observing unsuspecting people who are naked.. Variable (early adulthood)
Chronic
Sadism
Chronic
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.

Loneliness is particularly common. More rarely. so that heterosexual relationships can be intiated or maintained. including prejudice.114
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interest in playing with dolls. Some children refuse to attend school because of teasing or pressure to dress in attire stereotypical of their sex. ranging from: (i) Exclusive heterosexuality (ii) Sporadic homosexual encounters. the disorder becomes continuous with transsexualism. hepatitis and sexually transmitted diseases. anxiety. and a sustained pattern of overt homosexual arousal that the individual explicitly states has been unwanted and a persistent source of distress. guilt and other medical illness like AIDS. Diagnosis. Most children with this disorder deny being disturbed by it except as it brings them into conflict with the expectations of their family or peers. In a small number of cases. Homosexuality The essential features of ego-dystonic homosexuality are a desire to acquire or increase heterosexual arousal. Others may display serious signs of disturbance as phobias and persistent nightmares. or she has. a girl with this disorder claims that she will grow up to become a man (not merely in role) that she is biologically unable to become pregnant. that she will not develop breasts. This category is reserved for those homosexuals for whom changing sexual orientations is a persistent concern and should be avoided in cases where the desire to change sexual orientations may be a brief temporary manifestation of an individual’s difficulty in adjusting to a new awareness of his or her homosexual impulses. ‘Homophobia’ refers to irrational fear of homosexuality and societal attitudes. a penis. depression. or will grow. discrimination and harassment are distressing for male and female homosexuals.
. usually in adolescence and early adulthood (iii) Bisexuality (attraction to partners of both sexes) (iv) Exclusive homosexuality The individuals with this disorder is prone to dysthymic disorder. particularly girls. Peer relations with members of the same sex are absent or difficult to establish. The amount of impairment varies from none to extreme and is related to the degree of underlying psychopathology and the reaction of the peers and family to the individual’s behaviour. whom no other signs of psychopathology. Sexual behaviour is highly variable. Some of these children.

low self esteem etc. chromosomal and socio-cultural. Most problems encountered with young children can be broadly classified into problems of emotions or behaviour.14
Common Childhood and Adolescent Disorders
Like adults. children may experience disturbance in emotions. maternal diseases. Influences on Child’s Behaviour • Preconception factors i.e.. intensity of their desire for a child.e. favoritism as well as rejection. overprotection. family relationships and parenting styles are important..
. • Disturbed family e. disturbed interpersonal relationships. • Attitude of other significant person e. • Parents and the home i. preterm delivery • Postnatal factors such as • Establishment of a bond between parents and a child. poor academic achievement. age of parents.g. love for the child. antisocial family. friends and siblings. teachers. parental habits etc. environmental. It is distressing to the child as well as parents and the community.e. inadequate family. Factors like child’s temperament. parental health. behaviour and relationships which impairs their functioning. There is no one cause for these disturbances. • Prenatal factors i. It becomes imperative to identify these problems early because of several reasons: • Children would rarely seek help from professional agencies directly • Symptoms if left unchecked may persist into personality problems. fear of spoiling. Reasons are often multiple: genetic.g. psychological stress.. Judicious early identification would curtail needless suffering and avoid spiralling of problems.

and showed generally positive reactions . Three broad types of temperament were characterised: children who were regular. and a sizeable minority who were ‘slow to warm up’ to new situations but who adjusted eventually. Some other features of such a child are • Fidgetiness • Difficulty in remaining seated when required
. A very useful concept is that hyperactivity is indicated by the inappropriateness and undirectness of the activity.116
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Child Temperament Despite these environmental influences and stressors certain children are more vulnerable while some are less. When in doubt. It must be noted that high activity levels are typical in children who are normal 2 and 3 year olds. Comprehensive Evaluation Comprehensive evaluation of the child should include: • Clinical Interviews • School Report • Intellectual Functioning • Development Tests • Neurological Assessment For this reason. Children differ in their personality character or temperament. occupational therapist. The activity is inappropriate and undirected rather than purposeful or productive.the easy babies. whom Chess called the ‘mother killers’. Reasonably objective parents can recognise when the amount and degree of activity (constant and involuntary) is different than that of peers of the same sex. It was found that those who developed behavioural problems in later childhood were difficult temperament babies. mentally aged 2 or 3. overly nagged by adults and environmentally deprived. Excessive physical movement (beyond a normal or acceptable limit) is termed hyperactivity. highly exploratory and very intelligent. they can be suggested to visit a classroom or play area for children of the same age. Requesting a friend to observe and provide objective information regarding comparative activity levels is especially helpful. those who were almost the opposite. psychologist. but few are extraordinarily so and are considered hyperactive. as compared to the very active but purposeful and productive child. The physical movements of the child are excessive and beyond normal acceptable limits. A “difficult child”. children with problem are often seen in a multidisciplinary setting including inputs from pediatrician. special educator and speech therapist. predictable. Described below are some of the common childhood disorders ATTENTION DEFICIT HYPERACTIVITY DISORDER All children are active.

. preservatives and sugar. If one person in the family is diagnosed as ADHD there is greater probability of ADHD in another direct blood relation which suggests a genetic basis to ADHD. there is growing evidence that parents likely had little control over the cause of ADD/ ADHD. Allergic/medical conditions: Predisposition toward asthma. 2. it is not unusual for the parents to feel guilty or blame themselves. Parental education and support has been shown to be very helpful for families with an ADD/ADHD child and its value cannot be overemphasised. 4.Common Childhood and Adolescent Disorders
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Easy distractibility Difficulty in taking turns Blurting out answers even before question is completed Shifting from one incomplete activity to another Excessive talkativeness Poor listening skills Carelessness and tendency to loose things Engaging in dangerous activity with little consideration for possible consequences i. However. 7. Prolonged emotional deprivation. food allergies and ear infections. When parents have a child with any type of problem. aunt. Some suggested factors include: 1. Food additives. e. etc. The following are commonly accepted as the most likely causes: Causes The exact causes of ADHD are unknown. 5. most children with ADHD can live productive lives and can cope reasonably well with their symptoms. either by mouth or absorption. If properly treated. 6. 3. stressful life events may initiate or perpetuate ADHD. movie watching for 3 hours at a stretch. had a similar temperament or pattern of behaviour. Minimal and subtle brain damage during fetal development and early infancy. pre-maturity and so on..g. 8. lack of oxygen. uncle. Heredity/Genetic predisposition: Another member of the family—grandparent. Biological/physiological causes: Possible chemical imbalance that inhibits the efficiency of the neurotransmitters of certain portions of the brain. The issue of hyperactivity and inattention is further complicated by the fact that the same child who can’t sit still to finish dinner may be able to attend and persist in activity of his interest. as scientists and medical professionals learn more about the possible causes of this condition. Impulsivity. Pregnancy/birth complications: Premature birth.e. or history of prenatal exposure to drugs/alcohol. mechanical damage. colouring agents.
• • • • • • • •
. Lead poisoning: Ingesting toxic levels of lead. This may be caused by infection.

they improve self-esteem by improving the patient’s rapport with parents and teachers. knife. armed robbery) 7. individual psychotherapy. The sustained-release preparation does not have proven usefulness. CONDUCT DISORDER Prevalence ranges from 5–15% in studies. has used a weapon that can cause serious physical harm to others (e. threatens. but safety of the medication is suspect. It may include medication. Plasma levels are not useful. often initiates physical fights 3. Buspirone/Bupropion are also useful. mugging. (iii) Antidepressants if stimulants fail. brick. has stolen while confronting a victim (e. Clinical Features A repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated. extortion. has forced someone into sexual activity
.. given the risk of delinquency.g. gun) 4. with at least one criterion present in the past 6 months. often bullies. (a) Dextroamphetamine is approved by the Food and Drug Administration (FDA) for ages 3 years and over. broken bottle. has been physically cruel to people 5. (iv) Antipsychotics or Lithium if other medications fail but only with severe symptoms and aggression (concomitant disruptive behaviour disorder). and special education (especially with coexisting specific developmental disorder). Imipramine and Despiramine have shown some efficacy in studies..g. as manifested by the presence of three (or more) of the following criteria in the past 12 months. family therapy. (b) Psychological—Multimodality treatment is necessary for child and family. Stimulants decrease hyperactivity. purse snatching. or intimidates others 2.118
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Management (a) Pharmacological (i) Stimulants reduce symptoms in about 75%. Aggression to people and animals 1. The male-to-female ratio is 4–12:1. Conduct disorder accounts for many impatient admissions in urban areas. has been physically cruel to animals 6. These interventions are crucial in moderate or severe cases. may be best in ADHD with symptoms of depression or anxiety. (ii) Clonidine and Guanfacine are reported to reduce arousal in children with the disorder. a bat. (b) Methylphenidate is FDA approved for ages 6 years and older.

often lies to obtain goods or favours or to avoid obligations (i. It is crucial to discover and fortify interests/talents to build resistance to the lure of crime. alcoholism.g. shoplifting. If environment is noxious or if conduct disorder is severe. building. has broken into someone else’s house. paranoia and cognitive or subtle neurological deficits.g. Management (a) Pharmacological – Lithium or haloperidol is of proven efficacy in many aggressive children with conduct disorder. tutoring. is often truant from school. (b) Psychological – Multimodality as in ADHD. beginning before age 13 years 14..e. forgery) Serious violations of rules 13. Some children with conduct disorder have low plasma dopamine β-hydroxylase levels. Suicidal thoughts and acts and alcohol and drug abuse correlate with conduct disorder. has deliberately destroyed others’ property (other than by fire setting) Deceitfulness or theft 10. beginning before age 13 years General Considerations Conduct disorder is associated with family instability. SSRIs are useful for reducing impulsivity and aggressive behaviour. Currently. e. placement away from home may be indicated. Conduct disorder often coexists with ADHD and learning or communication disorders. It is crucial to explore for these signs. THE DEPRESSED CHILD Only recently has there been a growing awareness of the increasing number of depressed children under 12 years. individual or family therapy. “cons” others) 12. It often includes medication. and signs of severe psychopathology. it is estimated that 1 in 5 children have some form of depression. β-Adrenergic receptor antagonists deserve study.. has deliberately engaged in fire setting with the intention of causing serious damage 9. Propensity for violence correlates with child abuse. Carbamazepine has shown success. has stolen items of nontrivial value without confronting a victim (e. abnormal serotonin levels.Common Childhood and Adolescent Disorders
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Destruction of property 8. findings can guide treatment. or car 11.. often stays out at night despite parental prohibitions. but without breaking and entering.
. has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period) 15. family violence. including victimisation by physical or sexual abuse. or special class placement (for cognitive or conduct problems).

miserable. to substitute more reality-based interpretations for their usual interpretations. Peer group approaches have been found to be effective for children. To others. feelings. to monitor their negative thoughts. Some become detached and aloof. self-comforting activities to interacting with others. they prefer isolated. delinquent acts. Play therapy is sometimes appropriate with younger children. and suddenly do poorly in school. Rather than complaining of sadness. • Behavioural: Behavioural approaches designed to increase pleasant activities include several components such as self-monitoring of activities and mood. to challenge their negative thoughts with evidence. identifying positively reinforcing activities that are associated with positive feelings. Many of these approaches can be implemented individually. Delinquency often covers up feelings of loneliness and despair. children may have physical complaints (headaches. and decreasing negative activities. and rarely laugh. General Considerations Self-injurious behaviour occurs when people damage or hurt themselves. To make the situation even more serious. There is considerable evidence to suggest that interventions which emphasise treatment of the family. lose interest in playing sports or games. fatigue.” Common Treatment Approaches A large number of treatment strategies have been developed for the treatment of depression. lack of sense of humour. They may not feel like doing anything. and grown up. Approximately half of the adolescents in trouble with the law are depressed. and behaviour. hyperactivity. It may be hard to arouse their interest in anything. They may be tearful. increasing positive activities. Often. they may seem too serious. irritable.
. There may be mood swings and disturbed sleep patterns. solemn. while others appear overtly anxious. often have a soft monotonous voice. in groups or family therapy environment. stomach aches). Suicide is an extreme form of self-injurious behaviour that often occurs in depressed individuals. and not the “identified patient. school failure. They may feel rejected and unloved and not be easily comforted. and cling for support. 58 per cent of parents of depressed children are also depressed. and psychosomatic problems. and to focus on new behaviours outside treatment. Strikingly. there is a widespread professional opinion that depression at times underlies a variety of children’s behaviour problems such as bedwetting. (a) Psychological • Cognitive: Cognitive approaches utilise specific strategies that are designed to alter negatively based cognitions. This situation is called a “masked depression. truancy. Depressed patients are trained to recognise the connections between their thoughts. tantrums.” are critical to positive treatment outcome.120
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Clinical Features Depressed children rarely show joy or pleasure.

modelling by an individual or peer group. Paroxetine.g. self-evaluation and self-reinforcement. Sertraline. These drugs have been shown to be 50–70% more effective with adults than placebos and no other treatment. • Self-control: Self-control approaches are designed to provide the self-control strategies including self-monitoring. tricyclics (e. Sympathy or Revenge • Reaction to Tension • Family Context * Open Communication and Expression of Feelings • Promote Adequacy and Effectiveness • Promote Many Sources of Self-esteem • Model Optimism and Flexibility • Be Alert to Warning Signs. reflective listening. Phenelzine) but other classes have emerged as well. exploration and discussion of emotionally laden issues. SSRIs. Fluvoxamine. THE BEDWETTING CHILD Clinical Features Bedwetting or enuresis can be defined as the repeated. setting unrealistic expectations. An occasional wet bed is not considered problem. most bedwetters wet several nights a week or every night. responding to others. providing insufficient reinforcement. Fluoxetine. The object of this approach is to provide the child with an ability to obtain reinforcement from others. involuntary discharge of urine into the bed by a child age 4 or older. elicitation and active questioning on the part of the therapist. Patients are provided with instructions. setting unreasonable selfevaluation criteria for performance. refusing requests. Imipramine and Amitriptyline). Some common features of depressed children: What help can be given? * Guilt • Anger Turned Inward • Feeling Helpless • Gain Attention. (b) Pharmacological Several classes of medications are used with adult populations.. etc. The risks and side effects of medications and the findings that competent therapy and counselling interventions may be more effective restrict the use of medications with children. opportunities for role playing and feedback. Depressive symptoms are considered to be the result of deficits from one or more areas and are reflected in attending to negative events. (e.
•
.g. Very little is known about the safe use of antidepressants with children.. Love.Common Childhood and Adolescent Disorders
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Social skills: Social skills training consists of teaching children how to engage in several concrete behaviours with others. • Interpersonal: Interpersonal approaches focus on relationships. These drugs are not without side effects. social adjustment and mastery of social roles. making requests. Major types include. Citalopram. Treatment usually includes non-judgmental exploration of feelings. and too much self-punishment. and direct advice. Initiating conversations. development of insight. SSRIs as a class of drugs in children is safer.g. Escitalopram) and Monoamine Oxidase Inhibitors (e.

scolding. it is important to obtain the child’s cooperation and make it a joint effort to overcome the problem. avoid the extremes of being lax and indifferent about bladder control and being overly punitive. Above all. it is hard for him to learn new behaviours.e. has been found to alleviate the bed wetting in one out of every three bedwetters. Management (a) Pharmacological—The use of drugs. It has been suggested that if parents pressure a child to achieve night time control before the child is mature enough. In using any procedure. When a child is markedly anxious or fearful. Some investigators feel that if parents were to completely ignore the slow development of bladder control in the child. (b) Psychological—Some limited success has been achieved by limiting the amount of fluid a child can drink after 6 p. and/or anxious. physical illness. Secondary bedwetter: The most plausible explanation for bed wetting is a maturational lag. or shaming the child for wetting the bed. but none have been conclusively proven.. Others suggest that bed wetting is the result of a development lag interacting with maladaptive toilet training practices. severely punishing.m. Unfortunately most parents become quite upset about the bedwetting so that the child becomes anxious and discouraged which makes the problem worse. Primary bedwetter: Some external stress or emotional crisis that makes the child anxious.” In general. i. This seems to be inherited since the parents of enuretic children have a history of being enuretic themselves. the child may lose confidence and have greater difficulty in bladder control. has bowel control. while others try to reason with bedwetters to get them to “try harder.
. Some parents become emotionally cold and distant to the child. such as the birth of a new sibling. and by requiring the child to urinate before going to bed. Desmopressin.e. rather than attempting to force a method on a child. such as night time control. Punitive methods tend to make the child feel guilty. or a family move. these tactics are not only ineffective but may actually make the problem worse. matter-of-fact manner and show confidence in the child’s ability to eventually control this behaviour. slow physiological maturation of bladder control mechanisms. nasal spray. Causes There are many theories as to the underlying causes of bed wetting. inadequate. parents are best advised to respond to the bedwetting in a calm. and the secondary wetter who had achieved a significant period of night time dryness (at least 3 months) and then resumed bedwetting.. General Consideration In toilet training a child. and tablet oxybutynin are also useful. this would lead to spontaneous cure by the time the child reaches 7 to 8 years.122
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Two types of bedwetters have been identified in the literature: the primary bedwetter who has been wetting since birth. and is able to hold urine for several hours at a time. i. It is also wise to delay bladder training until the child is comfortable about daytime control. such as tricyclic antidepressants (Imipramine).

and no single symptom is pathognomonic.
. and the quality. communication. the bedwetting was soon eliminated. Reduce Stress: If the child had been dry at night and then started wetting again. variety. a family quarrel. You might also spend extra time during the day interacting on a one-to-one basis with the child in pleasant activities.Common Childhood and Adolescent Disorders
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Star Chart: Ask the child to keep a record of wet and dry nights. Median prevalence estimate is 4–5 per 10. urinates in the toilet. or the extended absence of a parent for any reason. This seems to be a logical consequence to the act of wetting. and sleeps through until morning. Night time Awakening: The first step in this procedure is to determine what time the child usually wets the bed each night. such as extra time alone with a parent. is given for each stage of improvement. Autism may occur across a range of functioning. While ignoring wet nights. The presentation of these symptoms varies greatly among individuals. Such a reward system helps motivate the child by giving him an incentive. Use this time to observe the child and to try to uncover any areas of conflict or unresolved anxiety. and a reward. you find that the child usually wets 2 hours after retiring. for example. The child is then to go to the toilet every other night without the alarm clock to fade out its use. After 7 consecutive dry nights is the criterion for further gradual reductions in time. and impairment persists throughout the lifespan. do what you can to reduce the child’s anxiety by giving extra attention. If. set an alarm clock to go off in the child’s room just before this time. feeling sure of your interest and support. When this procedure was used with a 13 years old girl who also cleaned her bed sheets when wet. although not always associated with the disorder. Clinical Features A constellation of symptoms is always seen in autism spectrum disorders. to 45 minutes. AUTISM Autism is developmental disability marked by significant impairments in social relatedness. and finally to 30 minutes. Do not scold or lecture when establishing this procedure. If an uncontrollable external stress seems to be triggering the bedwetting. a move to a new neighbourhood. and frequency of various activities and behaviours. and is often associated with mental retardation. the child arises. support. Star charts have been found to be particularly effective with young bedwetters. and a picture of his progress in reducing the habit. and a variety of other symptoms are often. a specific goal to achieve. The onset of autism generally is before age 3. to 60 minutes after bed time. Dry nights are highlighted on the chart with gold stars.000 M : F ratio is 3 : 5 or 4 :1. and understanding to the child. the parents praise the child for each dry night. When the alarm goes off. check to see if some stress occurred just prior to the resumption of bed wetting. At bed time sit with the child for 10–15 minutes of comforting talk to the child goes to sleep relaxed. Some parents require the school-age bedwetter to change the bed sheets after wetting and to see that the bed clothes get washed. such as the birth of a new sibling.

inappropriately mirroring the other’s behaviour. However. may range from an oddness in social interaction to an almost complete detachment and lack of responsiveness to other’s social initiations. Extreme Behavioural Problems A minority of children with autism exhibit extreme behavioural difficulties such as self abuse. childhood schizophrenia. emotional cues. Asperger’s syndrome and Rett’s syndrome are also included described with autistic features. Abnormal Capacity for Symbolic Play Children with autism are particularly lacking in the pretend play typical of preschool-aged children. high levels of aggression and destruction. (a) Pharmacological No pharmacological agent has proved curative but certain medications may be of benefit for specific symptoms such as self-injury. Restricted and Odd Behavioural Repertoire Typical toy play. carrying around). Children with autism demonstrate a particular inability to imitate others in typical ways. Much time is spent in a very limited range of activities. Pervasive Developmental Disorder Infantile autism. lack of social initiation and disorganised patterns of reactions to strangers and separations. individuals with autism rarely seek out play partners. the communication deficit is much more profound than impaired language alone. Social abnormalities may include poor use of eye contact. Management The goal of treatment is to reduce disruptive behaviour and to promote learning particularly language acquisition and communication and self-help skills. When age-appropriate play skills are present. and goal directedness is lacking in children with autism. marked by curiosity. Abnormal Communicative Development Much of the literature on autism has focused on deviance in the development spoken language. occasionally. The degree of impairment. stereotyped movements and over
. with disregarding the other or. sucking. which may consist of a few highly ritualised or repetitive ways of handling a few object (e. however. including doll play. and difficult to manage behaviour. shaking arranging. and watching television commercials or videos are typical interests of young children with autism. exploration interest in novelty. Water play. role play and dramatic play. Some other conditions such as disintegrative psychosis. and social smile. aggression.g. they are often inappropriately repetitive.124
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Primary Symptoms Include the Following: Abnormal Social Relatedness Social relatedness is always impaired in autism. watching things move or spin.

In profound or severe retardation. as long as children are receiving appropriate services. specific educational and therapeutic interventions are critical for stimulating development in all areas and improving the person’s adaptive functioning in all settings (home. roughly 25% of children with autism develop seizures beginning in adolescence or early adulthood. motivational and social features. Adolescents and adults with autism frequently need specific help in negotiating the complexities of life demands. Adolescence can be a difficult time for some individuals with autism. resulting in difficulties of problem solving the adaptation over a wide area of functioning. because children with autism tend to be the least social. Significantly sub average intellectual functioning. emotional. IQ remains stable across the lifespan. Another 30% are reported as achieving some degree of partial independence in adulthood. school. recreational activities. the slower rate of learning skills rather than absolute inability marks out the child. Fluoxetine and Citalopram: Reduce repetitive behaviour and impulsive aggressions. Nevertheless.e. MENTAL RETARDATION In mental retardation the individual operates at a level significantly below the intellectual functioning of the general population. The preschool years are typically the most difficult.
. Learning continues throughout childhood and adolescence. Haloperidol and Risperidone: May decrease stereotyped behaviours and agitation. Social skills groups. and vocational coaching and assistance can help them acquire skills necessary for a satisfying adult life. and cognitive abilities above the mentally retarded range (i. With appropriate educational and treatment services. but the severity of the social and communicative deficits tends to diminish as children grow older. Judgement of mental retardation must be based on rigorous intellectual assessment. least communicative. The most important positive prognostic indicators are functional language before age 5. chronic disability.Common Childhood and Adolescent Disorders
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activity. using relevant and valid test. Intellectual capacity is an essential element of daily living and normal scholastic and social problem solving skills. because of increased sexual behaviour and aggressiveness. The varying degrees of mental retardation should be identified based on comprehensive ability of the child and not upon any specific deficiency. carefully interpreted to allow for the child’s physical. Discriminating Features 1. IQ > 70). work and community). and have the most difficulties behaviourally.. 2. individual psychotherapy. Concurrent deficits or impairments in present adaptive functioning. (b) Psychological Autism is generally considered a lifelong. children with autism will show some improvements. Finally.

2.. use of community resources.org <http://www. Variable Features 1. self-care. Conclusion The psychiatric assessment of children and adolescents is a complex process. An IQ of approximately 70 or below on an individually administered IQ test.aap. The basic issue that is addressed is: whether the child has a problem that significantly interferes with his normal development.org <http://www. within this framework it is important to recognise individual differences between children and parents.org <http://www.psych. 2.psych. work.aap. the frequency of aberrant behaviours may be reduced.org <http://www. The components of the examination include meeting with the parents and the child to gather a complete history. Prevalence is higher in males.org> www.org> www. whether there are problems in social.org <http://www. self-direction. 3. academic or family functioning and whether there is an effective treatment that will allow the child to reach his potential free of interference from psychiatric morbidity. 3. it can be made less intimidating when a basic framework is followed.aboutourkids. leisure.ama-assn. Onset before age 18 years. Impairments in adaptive functioning in at least two of the following skill areas: communication. These techniques are quite successful in individuals with mild and moderate impairment. The rationale is that individuals acquire more appropriate means of obtaining desired ends. Management Many behavioural interventions are aimed at providing alternatives to unwanted behaviours for patients with mental retardation. Stereotypies and self-injurious behaviours are often found in the moderate to severe forms of MR. developing a treatment plan and presenting the results of the evaluation to the family. Yet.apa.126
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Consistent Features 1.org> www. Useful Child Psychiatry Web Sites About our Kids Advocates 4 Special Kids American Academy of Pediatrics American Medical Association American Psychiatric Association American Psychological Association www.a4sk.. However. Given the shortage of mental health professionals. Often accompanied by other psychiatric disorders.org> www.apa. collaboration with the general practitioners and family physicians becomes imperative in this regard.org>
Contd.
. home living.org www. obtaining the mental status examination of the child.ama-assn.a4sk. functional academic skills. health and safety. social-interpersonal skills.

due to aldosterone rise in midcycle. progesterone tablets. premenstrual change in endorphins. About 10% pregnant women have depression more commonly in first trimester which usually lasts less than 12 weeks. Etiology (i) Ovarian: altered ovarian activity i. Moos devised a 47 items “Menstrual Distress Questionnaire” consisting of 8 symptom groups. (iii) Other Agents: Pyridoxine. behavioural or cognitive disturbances should also be treated with psychotherapy for better outcome.e. 66% of women have some psychological symptoms during pregnancy. marriage. hysterical. prolonged or excessive stress e. (ii) Fluid and Electrolyte (hormonal): Increased water and electrolytes retention.. lithium. androgens. (iii) Other hormonal: Vitamin B or Magnesium deficiency: Changes in glucose levels. Prostaglandin inhibitor-analgesics (Aspirin etc. marital disharmony. depression. anxiety neurosis. (see clinical picture above). It is often associated with previous history of abortion or depression. death or separation of a parent. Treatment The different kinds of treatment available for this disorder are: (i) Hormones: Oral contraceptives. divorce. examination. (ii) Psychotropic Drugs: Sedatives. Clinical Picture Anxiety is common. Psychiatric Disorders of Childbirth (a) Psychological Problems in Pregnancy Epidemiology Minor psychological symptoms are common. Premenstrual syndrome is also called Late luteal phase dysphoric syndrome.). altered ratio of estrogen and progesterone. can precipitate premenstrual syndromes in 50–75 per cent of susceptible women. pregnancy being
. Diagnosis In 1968.. as is a tendency to irritability and minor lability of mood. (iv) Psychotherapy: The treatment of associated physical.g. Vitamin B-complex.Disorder Related to Women
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The syndrome of ‘pre. (iv) Psychological: Psychological e. increased melatonin. mood. however. diuretics. inadequate or obsessive personalities etc.g. dietary restriction of salt etc. peri or paramenstrual tension’ typically starts about 5 to 10 days before onset of menses and lasts till the end of menses. antihormonal (danazol) etc. bromocriptine. antidepressants. especially in the first and last trimesters. II.

Women frequently complain of anxiety. (b) Disorders of the Puerperium (i) Normal postpartum reaction. depression. These are more common in primigravida and in those who complain of premenstrual tension. irritability. Management (i) Counselling: Increased support by medical. (ii) Medication: Conjoint marital therapy or individual counselling of the husband may be used. operation. Etiology The following factors may be associated (i) Age of the mother (ii) Parity (iii) Relationship with her husband (iv) Type of family (v) Employment (vi) Physical or mental complications during pregnancy (vii) Attitude towards pregnancy (viii) Changes during pregnancy (ix) Other factors e. feeling separate and distant from the baby. increased neuroticism scores and denial of the pregnancy. unusual fears about self.
. Clinical Picture Unfamiliar episodes of crying. tearfulness. sleep) and a desire for intimacy. decreased thirst and increased urinary sodium excretion. the husband’s love and affection.g. about body changes. Minor tranquilizers and tricyclic antidepressants may be indicated in second and third trimesters.. hostility towards husband and parents. job. irritability. Immature personality. irritability. marital complications and anxieties about the fetus. nursing and other services as well as by family and reduction in the need to contact psychiatric services. (ii) Puerperal disorders (c) Transitory Mood Disturbances (Postnatal Blues) At least 50% women have a shortlived emotional disturbance commencing on the third day and lasting for 1 to 2 days. fatigue and mild vegetative symptoms (such as disturbances in appetite. emotional stability.130
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unwanted. insomnia and poor concentration. It is characterised by fatigue. First few days following delivery are psychologically stressful. dysphoria. This coincides with sudden weight loss. emotional lability.

(d) Puerperal Neuroses Postnatal depression is not only the most frequent but also the most disabling neurotic disorder at this time. Clinical Picture (See Table 1) — loneliness or worry about a physical illness — excessive anxiety about her baby’s health that cannot be diminished by reassurance — self-blame — sad mood — worry at her rejection of the baby — irritability and loss of libido — sleep difficulty — a fear that baby may not be hers — suicidal thoughts or a fear of harming the baby — the other symptoms include feeling tired. poor appetite. Predispositions Postnatal depression is associated with increasing age. a tendency to be more neurotic and less extrovert personalities.
. a previous psychiatric history. Breast-feeding is not contraindicated but should be discontinued if treatment with lithium carbonate is maintained. often on returning home and usually between day 3 and day 14. (ii) Others: There is evidence that depression and mood instability are maximal on the fifth postpartum day and that women with higher neuroticism scores are more likely to experience ‘the blues’. family distress. mixed feelings about the baby. problems in relationship with mother-in-law and father-in-law. Onset is usually within the first postpartum month. Epidemiology About 10 to 15% of mothers may develop a non-psychotic depression. childhood separation from father. physical problems in the pregnancy and prenatal period.Disorder Related to Women
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Etiology (i) Biochemical: The cause of postnatal blues is unknown but increased levels of urinary cyclic AMP and reduced plasma levels of free tryptophan have been reported. despondent and anxious. marital conflict. lower social class or a hereditary pre-disposition. Management The treatment consists of counselling and antidepressant drugs. decreased libido.

general contact obstetrician health visitor.2% Affective psychoses common. general practitioner. excitement or sudden withdrawal. Clinical Picture (See Table 1) — Puerperal psychoses are not widely held to be distinct and unitary form of psychosis but to be divided into affective psychoses (70%). if severe ssants neuroleptics. antidepreAdmit to mother and baby unit. — abnormal (unusual) behaviour such as restlessness. — persistent perplexity. (f) Puerperal Psychoses Epidemiology 1 to 2 per 1. 6–12 weeks up to 1 year if not Severe ‘blues’ may→ Postnatal depression→ Affective psychosis → → Profession of first Midwife (hospital). schizophrenic and organic types of psychosis are believed to be the more common than affective type. In India and other developing countries. Anxiety states and obsessive-compulsive neuroses may also occur and interfere markedly with care. Common symptoms of a puerperal psychosis are: — severe insomnia and early morning waking. health visitor.
Table 1: Spectrum of Mood Disturbances in the Puerperium Puerperal psychoses Frequency 0. sudden tearfulness or inappropriate laughter. but observation Counselling. schizophrenic and organic psychoses rare Peak time of onset 4–5 days after childbirth 2–4 weeks after childbirth 1–3 weeks after childbirth Duration Usually 2–3 days 4–6 weeks if treated. ECT. — lability of mood. schizophrenia (25%) and organic psychoses (2 to 5%). Midwife. disorientation or depersonalisation. Midwife (community).000 deliveries. lithium. antidepressants. psychiatrist practitioner (rarely) Psychiatric referral Virtually never Unusual Common—especially if marked behaviour disturbance Possible treatments Nil.132
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(e) Other Neurotic Disorders Phobias. counselling and advice about further pregnancy Postnatal blues 50% Puerperal neuroses 15% (13% depression)
.

(ii) Drugs and physical treatment should be given as appropriate to the symptoms. Poor prognosis is indicated by — a positive family history
. her feelings about the responsibility of motherhood. Outcome About 70% recover fully. — larger increases in camp during pregnancy. affective psychosis having a better prognosis than schizophrenic. excessive guilt. major tranquilizers may cause oversedation in baby. (iii) Psychotherapy usually of supportive kind is required. unexpected rejection of the baby or a conviction that baby is deformed or dead. Electroconvulsive therapy is very effective. (ii) Biochemical factors: Alterations in the hormonal levels of hypothalamic-pituitary-gonadal axis. persistent increase in alpha-2-adrenoceptor capacity. — urinary free cortisol excretion increases late in pregnancy.Disorder Related to Women
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— — — —
paranoid ideas that may involve close family relations or hospital staff. her reaction to assertion of her female role. — decreased endorphins levels are correlated with dysphoria. suicidal or infanticidal threats. a past history of bipolar disorder also predisposes to the development of postpartum mood disorder. lability and lethargy. The greater predelivery estrogen level (greater irritability) and lower postpartum estrogen level (sleep disturbance) and progesterone level (depression) are associated with symptoms of postpartum psychosis. — Sleep. If baby is breast fed. — alterations in thyroid hormone level. (iii) Psychodynamic factors: ‘Patients’ relationship with her own mother. Admission of both mother and baby together is always advisable if possible. (iv) Obstetrical factors: Obstetrical events other than parity have not proven to be significant.
Etiology The exact etiology is unknown but the following factors are important: (i) Genetic factors: A family history of major psychiatric disorder. decreased motor activity. surges at birth and then rapidly declines. depression or anxiety. Management (i) Hospitalisation: Puerperal psychosis is a psychiatric emergency. her relationship with her husband and his personality (overpassive or overdominant) and obsessive compulsive traits. Decrease in stage 4 sleep time and is correlated with mood irritability.

000 terminations. multiple somatic complaints (aches and pains). emotional instability.3 per 1. 1959) * * * * Vasomotor symptoms Nervousness Weakness Palpitations * * * * Paraesthesia Melancholia Arthralgia and Myalgia Formication * Insomnia * Vertigo * Headaches
(i) Gynaecological view: The various symptoms like depression. hysterical conversion symptoms and social and occupational maladjustment. IV. osteoporosis and other symptoms depending on personality.
. Menopause ‘Menopause’ refers to the time of cessation of menstrual periods and can therefore only be noted in retrospect. homicide. the incidence being about 0. reassurance and supportive psychotherapy. lack of confidence. The word ‘climacteric’s is defined as a critical phase in life when a major change is occurring but menopause is now also used with this wider meaning.
III. Termination of Pregnancy (Abortion) Serious psychiatric illness is very rare following termination. irritability.’ Management Counselling. a changed attitude towards sex. Clinical Picture
Table 2: Menopausal Index (Kupperman et al. depression. autonomic symptoms are attributed to menopause. The term ‘Menopausal syndrome’ has been used to describe symptoms related to estrogen deficiency and include—hot flushes. irritability.134
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— — — —
a history of schizophrenia neurotic personality presence of severe marital problems schizophrenic type of puerperal psychosis. anxiety. Clinical Picture The common psychological symptoms include—feeling of guilt and regret. Since most of the psychological reactions following an abortion are short lasting and tend to disappear themselves in a few weeks to few months.1 to 0. poor concentration. suicide. they are appropriately called ‘Postabortion blues. sweats.. atrophic vaginitis.

(ii) Psychoanalytic views: — a time of great loss of femininity and reproductive potential. — fluctuations in level of prolactin. The major influences on the risk of developing depression are reported as—worries about work. Combined oestrogen and testosterone implants may improve sexual problems especially loss of libido. cortisols. backache. social and family factors: Negative expectations of menopause may be culture bound. (iii) Cultural. adolescent children. — loss of femininity and fear of growing old and associated loss of self-esteem. palpitations. — a time of increased importance of penis envy. depression. Etiology (i) Biological factors: Abnormalities in — control of cortisol secretion.
. — response of thyroid stimulating hormone (TSH) to Thyrotropin releasing hormone (TRH). Management (i) Hormone replacement: Oestrogen therapy is believed to control many symptoms especially hot flushes and vaginal atrophy or dryness but the symptoms such as insomnia. irritability. — response of growth hormone to clonidine. vertigo. (ii) Psychotherapy: Explanation and reassurance. ailing husbands and ageing parents.Disorder Related to Women
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(ii) Psychiatric view: The belief that the menopause is a item of high risk for psychiatric disorder in women is not upheld in the psychiatric literature. FSH and Oestradiol. — upward LSH. fatigue and reduced libido are not relieved which respond to other medication such as antidepressants and benzodiazepines. TSH and Triiodothyronine.

16
Geriatric Psychiatry
Senescence is the normal process of growing old while Senility refers to the abnormal mental state which sometimes supervene towards the close of old life.
. The exact prevalence of these disorders in India is not known but major depression is believed to be the commonest disorder.0 per cent of the total population are above the age of 60 years. sleep-wake cycle and psychomotor behaviour. The study of the physical and psychological changes which are incident to old age is known as Gerontology while Geriatrics is the study of the causes and medical treatment of ill health associated with old age.8 per cent in India. oneiric thinking and confabulations. The disorders which are common in old age are: I. It is estimated that about 50 to 60 per cent of elderly have psychiatric disorders. as against 3. about 12 to 14 per cent of the people are above 65 years of age. although elderly often fail to show the more elaborate hallucinations. 7. POPULATION OF ELDERLY In USA and England. ORGANIC DISORDERS (a) Transient Cognitive Disorder (Delirium. Epidemiology The estimates of psychiatric disorders in the elderly are based on some Western studies. on admission to hospital. The incidence of delirium in various Western studies in reported as 15–35% in aged 65 years and above. Clinical Picture The clinical features are usually similar to those in younger subjects. According to 2001 Indian census. acute confusional state) Delirium is defined as an organic brain syndrome characterised by global cognitive impairment of abrupt onset and relatively brief duration and by concurrent disturbances of attention.

finding the way in public places. hepatic or renal failure. analgesics. aortic stenosis. The younger is the age of onset. Life expectancy is considerably shortened because of infections. (ii) Later stage: At a later stage. Electrolyte imbalance. The most common form of primary dementia is Alzheimer’s disease. more the symptoms of parietal and temporal lobe dysfunctions (language disorganisation. The correct diagnosis depends on the reliable history.
Table 1: Common Causes of Delirium in the Elderly Drugs Metabolic Infections Cardiovascular Intracerebral Antihistaminics. respiratory. dressing. haemorrhage. Fractures (especially femur.Geriatric Psychiatry
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Management The identification and treatment of the underlying organic cause is most important. embolism. handling finances. anemias. etc. Supportive measures include maintenance of fluid and electrolyte balance. hypothermia. aphasia. endocrine disease (e.g. neuroleptics. surgery. arrythmias. Cardiac failure.). postconcussional states. (b) Dementia It is the most common irreversible psychiatric disorder of the elderly. transient ischaemic attacks. which may have an onset in either the presenile or senile period (dividing line is age 65). diuretics. since the disorder involves first the higher order tasks such as work.
Trauma
Restriction of activities (i) In early stage: The primary dementias are invariable disabling. the simple self care tasks such as bathing. antiparkinsonian agents. use of toilet. Consciousness remains full and clear. myocardial infarction. In Western countries its prevalence among people above 65 years range from 1. a balanced sensory environment and good nursing care. hypnotics. meningitis.g. more rapid is the deterioration. general intellectual and specific cognitive capacities and social functioning.9% depending upon the sample studies and also the diagnostic criteria used. apraxia) and gait disturbances.
. encephalitis. hip). hypertensive encephalopathy.2 to 21. shopping or doing household chores. mobility. hypotension. investigations and special tests and mental status examination. space occupying lesions. hypertension. Urinary tract and chest infections and septicemia. Cerebrovascular accidents (e. continence and feeding are affected. digoxin. postictal. cerebral thrombosis. diabetes mellitus). vitamin B deficiency. The most striking features involve deterioration of memory.

mania. in low dosages are preferable.g. hysterical amnesia. sertraline. — Use drugs with a short plasma half life. thioridazine (risk of cardiotoxicity..g. pretreatment postural hypotension. — Use safer drugs e. 0.. arrythmias. which are found in about 10–20% of investigated cases. (c) Lithium is used with caution and the serum levels are maintained at the lower side (e.. trazodone. uncontrolled angina.g...g. haloperidol) as they may cause parkinsonian sideeffects and akathisia.138
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Differential Diagnosis (i) Delirium (ii) Depression (iii) Others e. fluvoxamine. postural hypotension etc. bupropion etc.g. aggression or agitation associated with dementia or depression. amnestic syndromes. (b) Antidepressants: The following precautions should be kept in mind: — Elderly are more prone to anticholinergic side effects. — Regular or prolonged use is avoided. — Avoid use of high potency drugs (e. fluoxetine.6–0. — Avoid use of drugs with more anticholinergic sideeffects e.7 meq / L) (d) Anxiolytics and hypnotics — Use about half the doses of benzodiazepines as those in adults. — Use of selective D2 receptor antagonists e. Ganser’s syndrome etc. sedation. urinary retention and delirium). olanzapine etc. The following points should be kept in mind: — Elderly are more sensitive to extrapyramidal side effects and tardive dyskinesia. delirium and the restlessness.g. — Review the patients (on hypnotics) regularly
. — Use antidepressants especially tricyclics in lower dosage range (because their half life is increased) and avoid tricyclics in acute recovery period following myocardial infarction or congestive heart failure. Pimozide or newer atypical agents such as risperidone. paranoid states. (a) Antipsychotic drugs: The main indications are schizophrenia. narrow angle glaucoma and prostatic hypertrophy. Management The treatment of cognitive impairment is first and foremost identification of reversible conditions. mianserin. Sulpiride.

g. (ii) Organic causes: Cerebral lesions especially of temporal lobe and diencephalon.3% of population over 65. These are ineffective. temazepam are the drugs of choice. Epidemiology — Prevalence is about 0. II. — 4% of schizophrenic disorders in men and 14% in women arise after age 65. pipradrol.6% of all psychiatric first admissions after age 65 are for paranoid psychosis. (f) Cerebral stimulants: This class includes penthylenetrazol. (g) Cholinergic drugs: The precursors choline and phosphatidyl choline (lecithin) are ineffective irrespective of dose or length of treatment.Geriatric Psychiatry
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— the intermediate to short-acting benzodiazepines such Oxazepam. methylphenidate and dexamphetamine. zolpidem. cyclandelate and isoxuprine. Rivastignine has been recently introduced but is costly. (i) Psychotherapy: It is of value in patients with lowered self-esteem. (e) Cerebral vasodilators: Dehydroergotoxine mesylate (Hydergine) is the most commonly used drug but other drugs used are papaverine. loss of customary role. FUNCTIONAL PSYCHOSES (a) Disorders Resembling or Associated with Schizophrenia (paranoid syndromes) History Roth (1955) used the term late paraphrenia while Fish (1960) preferred the term senile schizophrenia. (h) Electroconvulsive therapy: The following precautions should be taken: — use unilateral than bilateral ECT — use of a brief pulse stimulus preferred to reduce cognitive impairment — use modified type ECT (with good premedication) — use minimum number of ECTs — use limited to depressed patients with psychotic symptoms. — use hypnotics with short half life (without hangover. dependence potential or severe withdrawal syndrome) e. More common in females. as does the muscarinic against arecholine.
. — 5. Etiology (i) Genetics: There is increased risk of schizophrenia in relatives of late paraphrenics. Oral physostigmine produces a limited improvement. zopiclone. The cholinesterase inhibitor physostigmine infused intravenously may improve memory in ATD patients.2 to 0. (iii) Sensory deficits: About 30–40% of paranoid psychotics have impaired hearing.

The prevalence of depressive episodes is increased in females or if there is past history of depressive or neurotic disorder.
. — hallucinations may not be present or may be bizarre. social isolation. (ii) Organic factors — Cerebrovascular disease may act as a precipitant of depression. (iv) Environmental factors — A significant excess of loss in late onset depression compared with early onset. suspicious. Differential Diagnosis (i) Organic cerebral disease (ii) Depression Management Neuroleptics and depot preparations may be indicated. neuroleptics. 30–50% may be depressed. presence of physical ill health or there was a early loss of parent. Clinical Picture — usually insidious onset as a well-organised paranoid delusional system. — personality is frequently well-preserved. — The causes of symptomatic depression may include antihypertensive drugs. personality deviation. hypothyroidism or potassium deficiency. sensitive premorbid personality—paranoid or schizoid type. — mood is often congruous. depression is believed to be the commonest psychiatric illness among psychogeriatric population in contrast to Western countries where dementia is the commonest diagnosis. Electroconvulsive therapy may be used. — In the year following death of spouse. About 10% of the over 65s in a community has signs of depression whereas older people living in residential care.140
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(iv) Personality: The patients are often withdrawn. benzodiazepines. there is increased incidence of suicide. (b) Mood (Affective) Disorders (i) Depressive Disorder Epidemiology: In India. (v) Environmental: The precipitants often more uncover the pre-existing psychosis. Etiology (i) Genetic factors: There is much less evidence of familial incidence in late onset (over 50) compared with early onset. (iii) Personality: Neurotic depression may be related to obsessional premorbid personality.

If not. if no cause found.g. full assessment of social factors.
Table 2: Specific Problems in Elderly and their Management Problem Forgets Medication Forgets Familiar People Forgets. pessimism. irritable and miserable without any infectious gaiety—“Miserable Mania. treat with medication. There may also be delusions of guilt. Try and work out causes. — paranoid or sexual delusions or preoccupations.
Shouting
. But apparently causeless shouting is one of the most difficult problems in dementia. expansiveness and self-denigration. understand antecedents if possible. isolation. Calendar box. Try to find the cause (e.” — it may present as confusion or possibly delirium. (ii) Bipolar Disorder-Mania: About 5% of affective episodes in over 65. and counsel carer accordingly. Suicide is common in isolated men. investigate and treat any intercurrent physical illness.
Contd.. Mixed affective states are common. Repeats Himself Aggression Management Neighbour or Care assistant sets out medication. nihilism and persecution. anecdotal speech with little flight of ideas. Hypomania in elderly is characterised by — irritability — garrulous. give carer relief. try to reward silence with caring attention. Explain to the people. housing and family support. are diagnosed as mania or hypomania. pain). show them how to introduce themselves naturally Help carer to introduce distraction. There is a tendency to answer “don’t know” rather than confabulate (Pseudodementia).. poverty. — patients claim to be very happy but appear tense. deafness.Geriatric Psychiatry
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Clinical Picture Agitation is much common than retardation. if driven by paranoid ideas. — mixed mood states quite commonly occur with elements of irritability. socially isolated men. Management (a) General Measures: Hospitalization. Differential Diagnosis The common disorders from which depression needs differentiation are discussed in chapter 11 on “Mood Disorders”. and refrain from rewarding shouting. danger in elderly depressed.

so that they can give clear unembarrassed cues to patient at the time to orient him to the social context. Incontinence Reduce obstacles to continence (difficulty in getting out of chair or walking. venlafaxine. Pads often confuse a potentially continent. — Social measures. Tricyclic antidepressants. The use of nonsedating antidepressants and with low anticholenergic side effects e.. NEUROSES (a) Anxiety States Epidemiology Prevalence of anxiety disorders in the general population is around 10% of elderly women (65 years or more) with the majority being phobias especially agoraphobias. Poor prognostic indications are — Late Onset (onset after age 70) — Organic brain disease — Serious Physical disease — Senile habits — Uninterrupted depression for more than 2 years. regular reminders or actual taking to toilet. delusional depression or manic episodes.
.142 Problem Night time Restlessness
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Management
Reduce daytime boredom.
(b) Specific Treatment — Medication. awkward geography of house. home assessment. Reduce stresses of patient. III. resents) patient out of home. Stubborn through one trusted person. Wandering Outside the House Accept the risk. alternative daytime activity. less hazardous than drugs. Occupational therapy. Introduction to supportive friendly Catastrophic Reaction environment is adherence to Familiar Routines. change the door catches. Disinhibition of Sexual Behaviour Encourage open discussion of problem among carers. avoid them if possible. desipramine and fluoxetine may be preferred. Introduce change very gradually. Anger. Problems in the carer (too frail. provide commode for nocturnal micturition. carefully medication (Not Benzodiazepine). Outcome. preferably Clinging. Sertraline. avoid too early bedtime. Financial Incompetence Arrange to draw pension (as appointee). complicated clothing. bupropion. maintain clear diurnal rhythm in household. Major changes in the situation (through help into the home) or move the demented. Emotional Reactions to Disability. depressed. often very helpful.g. Tranquilizers are indicated in agitation. improvement of social support and development of “second careers” are all of great importance. constipation). — Electroconvulsive therapy (ECT). Rehabilitation measures are vital in all cases.

rapid breathing. vomiting. * Assess at home. — benzodiazepines in generalised anxiety disorder especially those with shorter (4–8 hours) half life e. bronchodilators. assess local resources also. supportive psychotherapy. rapid pulse and sweating. irritability and worried apprehension. friends. (iii) Other measures include adequate exercise. GENERAL GUIDELINES FOR MANAGEMENT The general principles of management include: (i) Early. dread.
. take a full history from patient. dizziness.Geriatric Psychiatry
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Clinical Picture — Emotional component: fear. chest pains. co-workers etc. simple relaxation routines and formal behavioural strategies may also help. depression. relatives. strengthening of the involvement in social network and reduction of environmental threats. — propranolol reduces somatic anxiety but add to sleep disturbance and is contraindicated in those with diabetes. — barbiturates are avoided. (ii) Medication — tricyclic antidepressants and MAO inhibitors in phobic anxiety. palpitations. zolpidem. correct and full diagnosis of medical and social aspects. lorazepam. phobic states etc. curtailment of excessive day sleeping. tremors. headache. cardiac failure or bronchial asthma. Diagnosis The common physical conditions which are likely to be misdiagnosed are — hyperthyroidism — hypoglycemia — excessive intake of caffeine — silent myocardial infarction — small stroke or cerebral ischaemic attack — withdrawal symptoms of sedatives. oxazepam. reassurance seeking. The other conditions which may need to be ruled out are dementia. * Assess the problem where it presents. L-dopa. Management (i) Reassurance and explanations to the patient. hypnotics or alcohol or antihypertensives — other drugs e.g. complains. zopiclone. coughing. — Behavioural component: distractibility. regular bed time rituals. (ii) Keep patient at home as long as possible. tension.g. — Somatic component: Feelings of respiratory restriction.

day centre. home helps etc. lungs. luncheon club or Geriatric homes also aid in management.
Treatment The possible modes of treatment are: (a) Drugs The following precautions should be taken * Beware of overmedication or undertreatment. * If at home.). * Explain treatment to relatives and involve relatives as appropriate. give small quantities with each prescription and supply large written instructions. (c) Hospitalisation (Special geriatric units) * Avoid institutionalisation * Build and maintain interest on unit * High staff-patient ratio * Treatment of patients with respect Emergency Presentations * Physical illness. psychological and mental assessment may be indicated.
. social workers. * Treat with the lowest effective dose. practical help (meals on wheels.144
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* * * * * *
This reduces confusion and danger of institutionalisation and encourages utilisation of local resources. Family support is the most important factor here and families must themselves be supported. Outpatient clinic support of patient and relatives may be very helpful. * Introduce medication slowly and carefully to avoid side effects and to increase compliance. problems explained and discussed. antihypertensives etc. kidneys. Maximise home support with community nurses. (b) Psychotherapy Patients may need long-term therapy but shorter individual sessions. * Assess physical condition (heart.). liver) and presence of other drugs (alcohol. Day hospital. It should pay attention to self-esteem and practical issues.). Multidisciplinary team work with clear definition of individual responsibilities may help. * Use a limited range of familiar drug. ensure correct accommodation (warden controlled flat etc. Assess with plasma levels if available. Admission to a short-stay psychogeriatric unit for full physical.

. geriatric centres. Care patients dress and grooming and praise on any accomplishment. Non-emergency Presentations * Depression (Mild to moderate). * Breakdown of support system. * Multiple handicaps gradually intensifying. and firmly to patients with hearing loss. Keep promises to patients faithfully. Arrangements for patients with visual defects to have assistance for safety. Special attention to depression that may reach a stage of suicide risk when a personal or health crisis occurs. These include: Maintenance of security and dignity and reinforcement of independence to the fullest extent appropriate to the patient’s condition. clock. * Neurotic illnesses. Report these to the dietitian.Geriatric Psychiatry
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* Effects of mediation. * Alcoholism. especially for food likes and dislikes. or community facilities require some special services and activities to live in dignity and comfort. * Dementia (Mild to moderate). slowly. * Major change of environment. Maintenance of the patient’s orientation: name of the place. calendar. * Paranoid illness. Observation of eating habits. Provide opportunity for women to visit a market. difficulty in chewing. Observation of any specific interest in an activity reported to a staff member. * Attempted suicide. be especially sensitive to the need for medication to relative pain. Staff members should speak clearly. Report complaints about dentures so that patients can be seen by a dentist. * Agitation or panic attack. NURSING CARE The elderly in nursing homes. and daily schedule in a convenient location. or any fixed ideas about food. Encouragement of friendship and communication with staff and other patients. If the patient suffers a painful condition.

suicide kills
. A thorough mental status examination will guide diagnosis and sound care. The Suicidal patient 2. 1. others. psychosis often impairs decision making capacity and ability to care for self. laboratory data and radiological evidence for medical causes of psychiatric morbidity. A medical evaluation involves checking medications. keeping safety for the patient. evaluation. We will briefly discuss some aspects of two psychiatric emergencies. or actions for which immediate therapeutic interventions are necessary. and disposition. missing no detail. systematic approach can make good work practice routine. suicidal patients demand protection. Delirious patients require medical attention. General Principles The principles underlying many psychiatric emergencies remain the same.17
Emergencies in Psychiatry
Definition A psychiatric emergency is any disturbance in thoughts. The Violent patient 1. Once you have guaranteed safety and thoroughly ruled out medical causes for the presentation. The Suicidal Patient Introduction Suicide is the termination of one’s life intentionally. feelings. Always err on the side of caution and appropriate management of psychiatric emergencies saves lives. labile patients may need chemical or physical restraint. formulation. vital signs. According to 1999 data from the Centre for Disease Control and Prevention. A careful. and oneself always at the forefront. consider psychiatric disorders. The emergent task at hand becomes that of triage. florid paranoia can endanger those in community.

A significant proportion. with teenagers and the elderly at highest risk. Rational thinking loss: Psychosis is a risk factor. It was noted that only 18% of suicidal patients communicated their intent to helping professionals. Depression: Fifteen per cent of depressive patients die by suicide. • Signs of depression • Behavioural changes • Giving away special possessions • Difficulty with appetite and sleep • Taking excessive risks • Increased drug use • Loss of interest in usual activities
. Organised plan: A well-formulated suicide plan is a red flag. Sickness: Chronic illness is a risk factor.000 persons. Warning signs • Suicidal talk by patient • Preoccupation with death and dying. while 69% communicated their intent to an average of three close relatives or associates. An excellent mnemonic for the major risk factor is “SAD PERSONS. It has been estimated that 90% or more of them can be shown to have a major psychiatric illness. Suicide was the eleventh cause of death (homicide was fourteenth). separated. men are more likely to succeed. The suicide rate for the young (15–24 years) was 10. In India. social and familial factors. Nearly 50% had seen a physician in preceding week. Ethanol abuse: Fifteen per cent of alcoholics commit suicide. The vast majority of people with suicidal intent have a major psychiatric diagnosis. Previous attempt: Ten per cent of those who have previously attempted suicide die by suicide.Emergencies in Psychiatry
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more people than homicide. Age: Age falls into a bimodal distribution. saw a physician within 30 days prior to their death.3 deaths per 100. Risk Factors Suicidal behaviour is the end result of a complex interaction of psychiatric. 73% within 12 months of their suicide. having responsibility for children is an important statistical protector against suicide. estimated as high as 70%. suicide is the second leading cause of death among college students.0). although men commit suicide more frequently (4. Women attempt suicide more frequently than men (3:1). Suicide and suicidal patient represent significant public health problem. Sex: Women are more likely to attempt suicide. or widowed is a risk factor. No spouse: Being divorced.” devised by Petterson et al. and 10% of patients with chronic schizophrenia die by suicide.1:1. Social supports are lacking. and the third leading cause of death between ages 15 and 24 years.

contingent. Area of focus includes appearance. Psychosis. chronic. Social withdrawal. It is necessary to limit the patient’s access to potentially self destructive methods like antidepressants medication. Untreated mood. Anxiety. liver function tests. initiate one-to-one watch. Always look for methods the patient might use in the immediate vicinity to injure himself or herself. encourage him or her to speak with you about it. regarding the patient. firearms etc. knives. Insomnia. If the patient has a plan. use of collateral information. however unpleasant or embarrassing. Intent. mood. Suicidal behaviour is a syndrome that cuts across rigid diagnostics lines. Regardless of the underlying diagnosis. The aim of somatic treatment of suicidal patients to treat diagnosed psychiatric condition. Careful assessment. thyroid function. and the management of suicidal patient involves many treatment modalities. Factors to be considered in the assessment of the acutely suicidal patients include: Assessment factors Mental status. A full current mental status examination is always a vital part of the assessment. It is important to remember that you cannot plant thoughts in the patient’s head. electrolytes. A supportive style. Sadness. Psychotic or personality disorder. All are associated with anxiety for the care provider doing the assessment. Treatment starts during the interview. Isolation.148
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Assessment It is often challenging to talk to patients about suicidal thoughts. If this supervision cannot be sufficiently accomplished in an outpatient setting. Uncommunicative presentation. Impulsivity. behaviour. level of psychomotor activity and thought processes. and/ or potentially manipulative suicidal patient. often proves therapeutic. Ensure medical clearance to expedite the initiation of pharmacotherapy. Should the patient be an active risk and unable to contract for safety. The clinician must first confront his or her own feelings. have been conceptualised as Para suicide. safety of the patient remains paramount. Hopelessness.
. Para suicide Self-destructive behaviour and nonfatal suicide attempts. Agitation. Management Suicide is a multi-dimensionally determined act. hospitalisation should be considered. Principles of acute intervention begin with adequate supervision of the suicidal patient. Plans. Recent major loss. Suicidal ideation. Active substance abuse. and acceptance of predictive limitations can be helpful. Common presentations include acute. Prior high lethality attempts. although difficult to categorise. Management depends to a large degree on diagnosis. and ECG and urine toxicology. with emphasis on encouraging the patient to share concerns. Routine tests include complete blood count with differential.

2. in an unlocked time-out room. physical and psychological effects on patients and staff. Definitions Seclusion: The therapeutic isolation of a patient. It represents the least restrictive form of seclusion. a finding that is true for private as well as public hospitals. Locked seclusion: The therapeutic isolation of a patient in a locked room designed specifically for the purpose of confining an agitated patient. and in the implementation of restraint and/or seclusion is valuable in. Literature review A literature review on the topic of seclusion and restraint reached on the following conclusions concerning the risks and benefits of this intervention: 1.Emergencies in Psychiatry
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High risk diagnosis includes major depression. verbal abuse. 3. Training in the prediction and prevention of violence. can significantly ameliorate underlying psychiatric diagnosis associated with suicide. Common examples include hyperactivity. It is nearly impossible to operate a program for severely symptomatic individuals without some form of seclusion or physical or mechanical restraint. Seclusion and restraint are basically efficious in preventing injury and reducing agitation. or in a partitioned area. 2. Agitation is a state of increased mental excitement and motor activity. 4. Antidepressants. staff role perceptions. Local non-clinical factors such as cultural biases. have a substantial influence on rates of restraint and seclusion. The Violent Patient Violence by patients towards clinicians is not uncommon and is serious problem. as well as adjunctive benzodiazepines and antipsychotics. Restraint and seclusion may have deleterious. and the attitude of hospital administration. reducing the rates and untoward effects of these procedures. mood stabilisers. Open seclusion: Methods of open seclusion include quiet time alone in a patient’s room. A number of studies indicate that approximately 10% of the patients seen in psychiatric hospitals manifested violent behaviour toward others just before being admitted to these hospitals. bipolar disorder. threatening gestures and language. in self-defense. Co-morbid alcoholism increases risk in every diagnostic category. It may occur in a wide range of mental disorders. and ECT. alcoholism and substance abuse and borderline personality disorder. schizophrenia. 5.
. Unmanaged acute agitation can lead to violence. As such acute agitation is a psychiatric emergency because agitation often precedes violence and requires rapid intervention. It is of two types. lithium. Learning how to evaluate and manage violent patients is important not only for the safety of society and of patients in treatment settings but also the safety of mental health professionals.

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Restraint: A confining apparatus commonly composed of leather or canvas. Indications for Seclusion or Restraint • To prevent harm to others • To prevent harm to the patient • To prevent serious disruption of treatment environment • As ongoing behavioural treatment Contraindications specific to seclusion: • The acutely suicidal patient (without constant observation) • The patient with unstable medical status • The delirious patient • The self mutilating patient (without constant observation) • The patient with a seizure disorder • The developmentally disabled patient. each staff member should grab a limb and bring patient backward to the ground.
. • Each decision. • Restraint devices are applied. observation. and measurement. • Nursing staff should observe patient at least every 15 minutes. When properly applied. • If patient does not comply. • Meals. pins. • Psychiatrist/staff must follow written guidelines of institution. fluids and toileting should be provided at appropriate times and with caution. • Adequate staff must be present (four) for implementation. • Psychiatrist/staff must take into consideration the medical and psychiatric status of the patient. Guidelines for seclusion and restraint • Not to be used to punish a patient or solely for the convenience of staff or other patients. or patient is carried to the seclusion room by four staff member. • Patient is searched for belts. Patient should be given seconds to comply by walking to the seclusion room. • Physician sees patient within 1 hour. • When decision is made to use seclusion or restraint. watches and other dangerous objects. as well as care must be documented in detail in the patient’s record. restraints maximally restrict physical movement without threatening the body parts. • Patient should be gradually released from or restraint.

Premonitory physical signs (clenched fist. The drug choice is based on the available routes of administration. Interviewing guidelines If the conversation is possible. sympathomimetics. such as delirium or dementia. potency and the side effect profile. For someone who is acutely agitated and an immediately danger to self or others. It is important not to express overt anger or hostility. try to quiet the patient. Does the patient suffer from personality disorder that may make the patient prone to impulsivity or to excessive anxiety in response to stress? Make a definite diagnosis so that a treatment plan can be developed. Current ideation. Protect yourself and the staff. Active substance abuse. For violence. Key points in assessment of acute agitation? Violence is outlined below: 1. including content of delusions 5. Assessment The time available for patient assessment will be dependent on the acuity of the presentation. It is also important to remain non-confrontational and to let the patient know that you will listen empathetically to angry complaints and concerns and that you will be honest with the patient about limits and treatment.Emergencies in Psychiatry
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Diagnosis Rule out an organic mental syndrome. benzodiazepines or antipsychotics are used. If talking is not effective isolate the patient and avoid excessive stimulation. Is there a treatable medical cause? Many medical conditions (for example. Abnormal vital signs suggesting autonomic abnormalities are the first clues of an organic disorder such as drugs or alcohol intoxication or withdrawal. with impaired reality testing? If the patient is psychotic and agitated. Usually. pacing) Management Behavioural. Physical restraint should be used if medications are ineffective and if violence or fight is impending. Is the patient paranoid and psychotic. Have a sufficient number of staff members present to restrain the patient if necessary. Verbal threats 8. emergency measures must be taken to avoid harm. If patient requires medication for sedation use it appropriately. medication may be indicated immediately. Previous history of violence 3. Stay calm and straightforward as far as possible. tranquilization may be necessary. Access to weapons 4. including alcohol 6. psychological and pharmacological interventions are used simultaneously. Obtain the patient’s vital signs if possible. Somatic conditions 2. Do not be punitive. Co-morbid antisocial personality disorder 7. anticholinergics and digitalis) can precipitate episodes of agitation. Be reassuring to patient and say that every one there is trying to help.
.

Table 1: Pharmacological Options in Emergencies for Violence Drug Lorazepam Haloperidol Olanzapine Chlorpromazine Dose (mg) 2–4 mg im or orally. use that drug again. the most frequently used medications were haloperidol and lorazepam. repeat every hour if im or every 4–6 hr if oral 2–5 mg im every 1–4 hr with maximum daily dose of 20 mg 10 mg im and repeat if necessary 25 mg im every 4 hours with increased dose over 1–3 days 12–36 34–38 Half-life (h) 10 –20
–
* im—intramuscularly. For long-term medication there is no one drug for treatment of violence because the underlying etiology for violence differs among patients. The new intramuscular formulations of atypical antipsychotics hold promise to quickly and efficaciously control acute agitation. In a survey. without side effect burdens of older typical antipsychotics. Early intervention is important to avoid further escalation to violence. often together and intramuscularly.152
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If the patient is taking a specific drug or has a history of responding to a specific drug. A combination of the two drugs is safe and is often used.
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or at least afflictions and most have local names. These disorders are called culture specific or culture bound syndrome. and troubling sets of experiences and observations (American Psychiatric Association. 1994 : 844) Though no clear cut diagnostic criteria have been devised as of now. majority of CBS share the following characteristics: • Categorised as a disease in that culture • Widespread familiarity in that culture • Unknown in other cultures
. course. In contrast. and social response are very often influenced by local cultural factors. Although presentations conforming to the major DSM-IV categories can be found throughout the world. The last two decades have witnessed an increased interest in the cross cultural study of psychiatric disorders. culture bound syndromes (CBS) are generally limited to specific societies or culture areas and are localised. 1994) which also includes a list of the most common culture bound conditions. Many of these patterns are indigenously considered to be ‘illnesses’. the particular symptoms. patterned. There is no objective biochemical or structural alterations of body organs or functions. locality-specific patterns of aberrant behaviour and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. According to DSM-IV culture bound syndrome denotes recurrent. The term culture bound syndrome was included in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association. some psychiatric syndromes are limited to certain specific cultures. However. diagnostic categories that frame coherent meanings for certain repetitive. folk.18
Cultural Bound Syndromes in India
Culture plays a decisive role in colouring the psychopathology of various psychiatric disorders. and the disease is not recognised in other cultures. Culture specific syndrome or Culture bound syndrome is a combination of psychiatric and somatic symptoms that are considered to be a recognisable disease only within a specific society or culture.

psychological and sexual symptoms. 1. Sometimes patient also reports of foul smelling semen and less viscous semen. clinical profile and nosological status of various culture bound syndromes in the Indian subcontinent. Disturbances of it can cause physical and mental weakness. Possession syndrome. in urine. valor and strength. aches and pains all over body. However there is no objective evidence of such a discharge. • Lassitude. Patient usually presents with various somatic. culture bound suicide (sati. Of all seven. Compulsive spitting. Jhinjhinia etc. Thus the belief in precious and life-preserving properties of semen is deeply ingrained in Indian culture. • Easy fatigue. The chapter will discuss the Socio-demographic. is harmful. Gilhari syndrome. The belief is further reinforced by traditional healers and perpetuated by friends and elders who had suffered from this syndrome. • The term was first used by N. weight loss. Semen is considered to be the most precious. Koro. Ascetic syndrome. • Tingling and numbness in various parts of body especially peripheries. • Sadness of mood.
. On the other hand.’ Shukra is the word used for sperms in Sanskrit. often associated with sexual impotence. nocturnal emissions etc. its preservation will lead to health and longevity. • A whitish discharge is blamed by patient to be responsible for the physical and mental symptoms which patient suffer from. • Excessive worrying. Charak Samhita (ancient text of Indian Medicine) describes a disorder resembling Dhat Syndrome by the name ‘Shukrameha. common culture bound syndromes are Dhat syndrome. masturbation. Dhatus are elixir of the body. Patient attributes it to the passing of whitish discharge. Dhat Syndrome Dhat syndrome is a clinical entity recognised both by general public as well as medical practitioners in which nocturnal emissions lead to severe anxiety and hypochondriasis. Patient complaints of following symptoms: • Generalised weakness. loss of attention and concentration. This gives rise to belief that loss of excessive semen in any form e.g. • Loss of appetite. • Panic attacks. Wig in 1960. Bhanmati. Susruta Samhita (ancient Indian text of surgery) has described 7 Dhatus in the body. Another term denoting semen is ‘Veerya’ which in Sanskrit means bravery.N. santhra). Dhat is derived from sanskrit word ‘Dhatu’ meaning precious fluid.154
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• No objectively demonstrable biochemical or organ abnormality • Treated by folk medicine/traditional healers In India. believed to be semen (Dhat).

Was seen mostly in Upper Castes notably Brahmins and Kshatriyas. Many religious shrines hold special annual festivals where hundreds of people get possessed simultaneously. Present all over the country.
• • • •
. Culture Bound Suicide Various types of culture bound (culturally sanctioned) suicides are as follows: (a) Sati: self-immolation by a widow on her husband’s pyre. Banned in India since 19th century. Only one known case since 1904 (in Rajasthan). In majority of cases there is absence of any physical illness like diabetes. This is usually seen in rural areas or in migrants from rural areas. Treatment mainly consists of dispelling of myths by psychoeducation. anxiety disorder may be present. Feelings of guilt (especially towards masturbation during adolescence). Sati the wife of Dakhsha was so overcome at the demise of her husband that she immolated herself on his funeral pyre and burnt herself to ashes. Concomitant psychiatric morbidity like depression. Patient speaks in a changed tone. Treatment antidepressants and anxiolytics are helpful in certain cases. Patient is possessed. Also to decrease any secondary gains patient may be getting from this behaviour. Possession Syndrome Diagnosable under dissociative disorders in ICD-10. even symptomatic relief (of severe anxiety that these patients suffer) with the help of medications in initial stages of treatment is required to gain confidence of the patient. local genital abnormalities. usually by ‘spirit/ soul’ of deceased relative or a local deity. treating any underlying psychiatric disorder. These people are looked upon as special by their families and villages which reinforce the secondary gains. Sexual complaints are that of premature ejaculation and erectile dysfunction. Pakistan and even in China (Sen-k’uri). Syndrome is seen in all parts of India. Majority of these patients are females who otherwise don’t have any outlet to express their emotions. Also seen in surrounding countries like Sri Lanka (Sukra Prameha). Treatment includes careful exploration of underlying stress which precipitated the possession attack.Cultural Bound Syndromes in India
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Forgetfulness. The syndrome is seen usually in people from lower socioeconomic strata who seek help from traditional healers before reaching Hospitals. sexually transmitted diseases. 2. somatoform disorder. According to Hindu mythology. reassuring the patient. 3. even gender changes at times if the possessing soul is of opposite sex. Since then her name ‘Sati’ has come to be symptomatic of self-immolation by a widow.

severe sexual abstinence. Koro • Seen in northeastern states like Assam • Fear of genitalia retracting into abdomen leading ultimately to death • Seen in both sexes • Person applies external retractors to the genitalia in form of clamps. conversion disorder. • Nosological status unclear
. lack of concern with physical appearance and considerable loss of weight 6. later even refusing to take them • Recently 4 cases were reported from Rajasthan 4.156
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(b) Jouhar: Suicide committed by a women even before the death of her husband when faced by prospect of dishonour from another man (usually a conquering king) • Most notable example is Rani Padmini of Chittor (Rajasthan) to evade the invading army of Sultan from Delhi in 15th century • More recently. hundreds of women killed themselves by jumping in wells during (1947) partition of India to avoid rioters (c) Santhara/Sallekhana: Voluntarily giving up life by fasting unto death over a period of time for religious reasons to attain God/Moksha • Seen in Jain community who celebrates these events as religious festivals • Person initially takes liquids. Jhin Jhinia • Occurs in epidemic form in India • Characterised by bizarre and seemingly involuntary contractions and spasms • Nosological status unclear 7. anxiety disorder. practice of religious austerities. It is believed to be due to psychiatric illness i. chains etc. Bhanmati Sorcery This CBS is seen in South India. dysthymia. to avoid it retracting back • It may occur as epidemics • Described as a syndrome in ICD-10 and DSM-IV 5.e. schizophrenia etc. Ascetic Syndrome • First described by Neki in 1972 • Appears in adolescents and young adults • Characterised by social withdrawal.. somatization disorder.

the God Ganesha’s idols drinking milk all over India in 2006 which lasted for almost a week. in 1993—gives description of an atypical hysteria epidemic in a tribal village of the State of Tripura. India. refusal of food and intermittent mimicking of animal sounds. The cardinal feature was an episodic trance state of 5 to 15 minutes duration with restlessness. It is popularly attributed to an increase in the “inner heat” of the body often due to dehydration. attempts at self-injury. The illness was self-limiting and showed an individual course of one to three days duration. Applying a few drops of sesame oil or castor oil in the navel and the pelvic region 2. eight female and four male. It is usually treated by the following: 1. were affected in a chain reaction within a span of ten days. Gilhari Syndrome • Characterised by patient complaining of small swelling on the body changing its position from time to time as if a gilhari (squirrel) is tavelling in the body • Reported from Rajasthan (Bikaner) • Not much literature available • Nosological status not clear 10.Cultural Bound Syndromes in India
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8. A report by Choudhary et al. Mass Hysteria • Short lasting epidemics of Mass Hysteria where hundreds of thousands of people were seen to be believing and behaving in a manner in which ordinarily they won’t. inability to identify family members. running away. Suudu It is a culture specific syndrome of painful urination and pelvic “heat” familiar in South India. Having an oil massage followed by a warm water bath 3.g.
. Intake of fenugreek seeds soaked overnight in water The problem has also been known to exist in other parts of South India and the methods of treatment are also similar 9.. • E. especially in the Tamil culture. inappropriate behaviour. Twelve persons. It occurs in males and females.

These include issues related to the rights of the patient while giving consent to treatment. Because of subnormal intellect or otherwise being incapable to manage their affairs by reason of mental illness. A person with unsound mind has different provisions under some particular situations. Others often take advantage of their lack of understanding or subnormal intellect.19
Legal and Ethical Issues in Psychiatry
All of us are bound by the legal system of the land and the law of the country treats everyone to be equal. 3. under certain situations where a citizen is incapable of carrying out the responsibilities of a normal citizen by reason of unsoundness of the mind. confidentiality. Law of the land takes a different stand for such unlawful activities. Forensic psychiatry deals with the legal aspects of psychiatry. These include
. they are generally ignored and looked down upon. they require someone else to look after them or manage their affairs. However. etc. the law takes a different stand. Society’s attitude towards the mentally ill has not remained favourable. Some mentally ill persons lack insight into their illness and under the influence of the illness they are incapable to evaluate the consequences of their actions. The situations under which law interacts with psychiatry make the domain of legal or forensic psychiatry. by reason of their mental illness develop suicidal or homicidal tendencies. statutory and regulatory laws. professional negligence. 5. Mentally ill persons are vulnerable to exploitation. Why should there be different provisions for the mentally ill: 1. 2. 4. The first aspect covers the practice of psychiatry as defined through the constitutional. these tendencies may be different from the ones experienced by the normal people. The second aspect relates to psychiatry serving the needs of the legal system. The law and the practice of psychiatry is very wide and has two dimensions. voluntary and involuntary treatment. Due to these reasons it becomes necessary to have separate provisions for the mentally ill. record keeping. Some mentally ill. doctor’s responsibility.

Patient can be admitted on voluntary basis and under reception order as well. 2. Lunatic asylums for their custodial care which soon degenerated into the institutions to inflict all kinds of cruelty on the inmates were built. They were considered to be the victims of the curse… in league with evil spirits… possessed by ghosts and so on. criminal responsibility. A British example illustrates it. detention and care of the mentally ill in a Psychiatric Hospital or Psychiatric Nursing Home. such as. 16th century onwards.Legal and Ethical Issues in Psychiatry
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issues concerning with patient’s competency. Laws Related to the Care of Mentally Ill Historically. The law comes in contact with psychiatry at many points. democratisation of the society. More elaborate laws related to their custodial care (known as Lunacy Acts/Mental Health Act) came and special provisions in civil and criminal laws related to mentally ill enacted in accordance with their status. safeguards against any kind of exploitation and proper monitoring of their care while they are inmates in the psychiatric hospitals. Admission. increased scientific knowledge. General laws of the land in relation to the mentally ill. which did not apply to Jammu and Kashmir state. human rights movement and many other factors contributed to improve the status of the mentally ill. it also provides guidelines for the protection of their human rights. New provision for admission to the hospital has been added wherein an uncooperative or unable to give consent patient can be admitted under special circumstances. The Act extends to whole of India unlike the Indian Lunacy Act. mentally ill were variously treated. to stand trial. This Act abandons the older and derogatory terms used in Indian Lunacy Act of 1912 such as Asylums and Lunatics and are replaced by the terms psychiatric hospitals and mentally ill persons. Can such a patient be held responsible for his action when he is living entirely in a different world dominated by his delusions. competency to manage one’s own property. civil responsibility of a mentally ill. his criminal responsibility. 1912. etc. With the dawn of 20th century. which is popularly known as McNaughten’s Rule(s). Criminal Responsibility A crime committed by a mentally ill may be the result of delusional experiences the patent was having at the time of committing the crime. marriage. 1987 replaces the Indian Lunacy Act of 1912. tortured and looked down upon. These can be broadly classified into two groups: 1. McNaughten was a young Scotsman who harboured delusions against the then British Prime Minister Sir Robert
. civil responsibility like testamentary capacity. These laws are as follows: Mental Health Act The Indian Mental Health Act. neglected. The Act also provides for creation of Mental Health Authority both at central and state level to monitor and regulate mental health activities. there appeared a trend of isolating them in order to protect rest of the society. The Mental Health Act provides not only for the custodial care of the mentally ill.

’ So. by reason of unsoundness of mind. He followed the Prime Minister wherever he went and decided to kill the Prime Minister before he could harm him. an idiot (mentally retarded person) is not liable in criminal law. Under Indian law. Suicidal attempt is an unsuccessful suicidal act with a non-fatal outcome. Sir Robert Peel and other prominent persons were outraged. shall be punishable with simple imprisonment for a term which may extend to one year and shall also liable to fine. Section 309 of Indian Penal Code (IPC) states that ‘whosoever attempts to commit suicide and does any act towards the commission of such offense. which are immortalised in the history of Forensic Psychiatry. is incapable of knowing the nature of the act or that he is doing what is either wrong or contrary to law. Criminals who later become mentally ill. A person who is guilty but insane. He must satisfy the above mentioned rule. who at the time of doing it. In an attempt to kill the Prime Minister. suicide and suicidal attempt are punishable offenses. The jury. have now come to be known as McNaughten’s Rule(s). in Section 84 of Indian Penal Code (Act 45 of 1860).160
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Peel that the Prime Minister wanted him to be killed. on the other hand. The law classifies ‘criminal lunatics’ into three classes: 1. McNaughten shot at Edward Drummond. An undertrial. Suicide and Suicidal Attempt Suicide is a type of deliberate self-harm and is defined as a human act of self-intentioned and self-inflicted cessation (death). is an attempted suicide where person performing the action never intends to die by the act. 2. mental hospital) for treatment. found McNaughten ‘not guilty by reason of insanity. It has been embodied in the Indian Criminal law. some of these persons may accidentally die during the act. It is believed that 2–10% of all persons who attempt suicide. Attempted suicide is more common in women while completed suicide is 2–4 times common in men. in
. In slightly modified from McNaughten’s Rule(s) are adopted by many countries even now.’ Section 309 of IPC was repealed by the Supreme Court of India in 1994. which is done by a person. This states: ‘Nothing is an offence. A person who is guilty but insane is a criminal lunatic who is acquitted by reason of insanity but detained in a psychiatric hospital (lunatic asylum. 3. who cannot stand trial because of mental illness. As per law. The answers. after testification by 9 physicians. eventually complete suicide in the next 10 years. However. It ends with a fatal outcome. 15 prominent judges were invited by the House of Lords. A suicidal gesture.’ Queen Victoria. They were asked to respond to a series of questions on criminal responsibility. Prime Minister’s secretary by mistake. However. Following this. a mentally ill person is not protected ipso facto.

(vi) A will is effective only after the death of the testator. (viii) No person can make a will while he is in such a state of mind. Sometimes a doctor is required to examine the state of mind of the testator. (iii) A beneficiary from the will cannot be a witness. (v) The testator is free to revoke the will any time before his death. due to whatever reason (intoxication. Civil responsibilities of a mentally ill person is generally questioned under the following situations: 1. may dispose of his property by will (Section 59. a five judge constitution bench of the Supreme Court again made ‘attempted suicide’ a punishable offense. who is incapable of understanding the nature of the act. (ii) The testator should sign the will in the presence of at least two witnesses. (iv) If the testator is seriously ill he must be made to read out aloud the will in the presence of the doctor.
. (iii) Whether he knows his exact relationship with the beneficiaries and the likely consequences of the will. not being a minor. 1925). Indian Succession Act. (vii) A mentally retarded person. This applies to both civil and criminal proceedings in the court of law. Civil Responsibility It is presumed that every person is sane and the contrary must be proved. it cannot be a just verbal communication though it is not necessary to register it. While examining such a person the doctor should keep the following points in mind: (i) Whether the testator knows the act he is doing and its consequences. cannot make a will. (v) The doctor has to ensure that the testator is not under the influence of any kind of intoxicant while making a will. (vi) Testator should not be under the influence or pressure of some other person while making a will. (ii) Whether he is aware of the extent of his property. Testamentary Capacity A person can will his property to someone before his death and this testamentary disposition is regulated by the Indian Succession Act (Act 39 of 1925). The following points need to be observed at the time of testamentary disposition: (i) The will must be in writing. illness or other cause) that he does not know what he is doing.Legal and Ethical Issues in Psychiatry
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March 1996. (iv) The testator appoints an executor who will execute the will after the death of the testator. (vii) Every person with sound mind.

or has been suffering continuously or intermittently from mental disorder of such kind and to such an extent that the petitioner can not reasonably be expected to live with the respondent. neither party. However. 3. on the discretion of the judge and the jury. the conditions for a Hindu marriage are that at the time of marriage. If she is married. or (c) Has been subject to recurrent attacks of insanity or epilepsy. The Act provides for punishment of Rs. Section 5(ii) introduced by Act 68 of 1976. has been suffering from mental disorder of such a kind or of such an extent as to be unfit for marriage and procreation of children. If a consent for marriage is obtained by fraud …. the fact of the mental illness or treatment for the same. This is as per Hindu Adoptions and Maintenance Act (Act 78 of 1956). Marriage According to the Hindu Marriage Act (Act 25 of 1955). 1872 a lunatic is not competent to give evidence if he is prevented by virtue of his lunacy from understanding the questions put to him and giving rationale answers to them (Section 118). Divorce can be granted under Section 13 of the Act on petition presented by either spouse on the ground that the other party ‘has incurably of unsound mind. A person capable of giving in a child for adoption should be of sound mind. sale. Narcotic Drugs and Psychotropic Substances Act (NDPSA). Witness Under the Indian Evidence Act. Dangerous Drugs Act. dumb and blind persons who understand the nature of the act can make a will. transport.162
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(viii) Deaf. 1985 This Act replaces the earlier Acts. 1930 and the Opium and the Revenue Laws Act. import. A marriage solemnised in contravention with this condition shall be voidable and may be annulled by a decree of nullity under Section 12 of the Act. 4. can make a will. Adoption Any Hindu male who is of sound mind and not a minor can adopt a child with the consent of his wife. (b) Though capable of giving consent. provided she is of sound mind. NDPSA came into force on 16th September 1985 to regulate production. possession. export. (a) Is incapable of giving a valid consent due to unsoundness of mind. (ix) A mentally ill person in lucid interval wherein he is capable of understanding the nature of the act.
. one lakh of fine with rigorous imprisonment of 10 years. Any Hindu unmarried female with sound mind and not being a minor can adopt a child. the Opium Act. 1857. her husband who is of sound mind can adopt a child. ‘as to any material fact and or circumstance concerning the respondent.’ for example. 2. such a person can give evidence during a lucid interval. purchase or use of any narcotic drug or psychotropic substance. 1950.

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The Persons with Disabilities Act. Protection of Rights and Full Participation) This Act provides for inclusion of mental illnesses in the purview of disability. For Any Charge of Malpractice • Doctor-patient relationship: putting the doctor in a caring role • Acceptability and standard of care provided • Deviation from standards and norms
. (ii) a physician and (iii) a psychiatrist.” In case of medical practice. Patient welfare is of utmost importance wherein autonomy of patient has to be maintained. Benefits are available for disability above 40%. creed. Treatment has to be humane with professional competence on the part of the treating psychiatrist. Four mental illnesses are included for disability. This may be the alleged negligence on the part of the treating practitioner. Confidentiality of the patients’ problems has to be maintained and his secrets are not to be divulged to others. Medical Malpractice Guiding principle is. 1995 (Equal Opportunities. Psychiatric disability is measured with Indian Disability Evaluation and Assessment Scale (IDEAS). Obsessive Compulsive Disorders and Dementia. Moderate 75%. Nothing has to be hidden from the patient and no discrimination has to be observed because of caste. Bipolar Disorders. Exploitation of patient in any form is unethical. A Medical Board to issue a disability certificate comprises of (i) medical superintendent of the hospital or his nominee. Mental Retardation Disability is measured with Intelligence Quotient (IQ). • And that this was the direct causation. Section 2(i) recognises Mental Illness and Mental Retardation as a disability. The board so constituted is competent to issue disability certificate. • There was a deviation from standards of the treatment. Medical malpractice is a non-criminal civil wrong arising from the patient or caregiver’s perception that the highest standards of medical care were not maintained. This Act is also helpful in psychosocial rehabilitation. these are Schizophrenia. These are: Mild (IQ 50–69) 50%. • As a consequence a damage occurred. There are four elements of malpractice: • Duty was not properly performed by the treating physician. “no person shall be harmed by the act of other person. no harm is to be caused to the patient by the treatment of the treating doctor. Severe 90% and Profound 100%. religion or any other factor. Ethical Issues in Psychiatry In practice of psychiatry ethics includes the safeguards of the psychiatric profession and ensure high standards of professional conduct.

Psychoeducation of caregiver and the patient is essential and they should be informed of possible outcome of the treatment in clear terms. Proper documentation of the treatment should be there. restraint (human right violation of the patient) forcibly administering treatment. To Avoid Possibility of Malpractice There should be a good doctor-patient relationship. It may be referred to later on. seclusion.164
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In psychiatric practice: invasion of privacy. The treating doctor should adhere to standards of caring and should follow only the accepted norms.
•
. involuntary admission. There should be a continuing dialogue with caregivers should be there.

careful monitoring of lithium levels. give propranolol (40–100 mg/day). — Thyroid function should be checked every six months. Therapeutic and toxic ranges refer to the ‘basic’ level.6–1. lower the dosage Lower the dosage. and ECG and serum T4 and TSH levels are required. — 24 hours urine volume should be done every 6 months and an ECG should be performed every year.4–0. Benzotr peroxide (5–10%) topical solution. The fasting blood sample is taken 12 hours after the last dose because of ‘peaking’ of levels. — Lithium is distributed in total body water.2 meq/I (mOsm/L).0 meq/I Children and Elderly—0.. Absorption and Excretion Lithium is administered as carbonate (most often). Therapeutic levels—0.
. headaches Management Give lithium after meals. — There is no protein binding and no metabolism.8 meq/I. give smaller doses more often. fasciculations. — Monitoring plasma levels. renal side effects are the commonest. add amiloride (5–10 mg/day). — Absorption is rapid and is complete within 6–8 hours. Preliminaries to Lithium Treatment — A full blood count.5–2%) topical solution Usually resolve with first few weeks of treatment
Contd. It is excreted unchanged by kidney. Breast milk contains about one-third and saliva contains about twice that of serum lithium. creatinine clearance.Psychopharmacology
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Dosage Depending upon serum levels (about 600–1800 mg daily). Serum levels peak at 3–4 hours. During long-term maintenance therapy. try slow-release preparation.. citrate or acetate salt. consider adding a benzodiazepine Try slow-release preparation. though neurological side effects (especially tremors) are not uncommon. In acute administration. lower the dosage. erythromycin (1. Prophylaxis—0. Side Effects and Management (See Table 8)
Table 8: Side Effects of Lithium and their Management Side effect Gastrointestinal complaints Tremor Polyuria-diabetes insipidus Acne Muscular weakness. followed by monthly (after stable levels are achieved) and then every 2–3 months.5–1. the gastrointestinal side effects are the commonest. — The lithium treatment is monitored initially by weekly serum levels (an estimation is done 5–7 days after any dosage change). plasma electrolytes and urea.

— Zopiclone: A pyrollopyrazine. — Atypical compounds—Buspirone. blurring of vision. impaired psychomotor performance. anticonvulsant and muscle relaxing properties. cross tolerance with barbiturates and alcohol and coma. CNS STIMULANTS Indications (i) Hyperkinetic syndrome (ii) Narcolepsy (iii) Enuresis (iv) Obesity (v) Depression
. It is completely metabolised and its half life is 2 to 3 hours. has very high affinity for central BZ receptors. confusion. hence anxioselective. It is given in the dose of 10-30 mg/day (in divided doses). no dependence and no withdrawal syndrome. depression. gastric upset (nausea. an azaspiro-decanedione. headache. light-headedness and diarrhoea. Benzodiazepines may produce nightmares. VI. aggression. disinhibited behaviour. bodyaches. impotence. metallic taste and headaches. It lacks hypnotic. It is a potent dopamine stimulant which indicates the role of dopamine in the aetiology of anxiety. vomiting. Buspirone is a selective dopamine autoreceptor antagonist. ataxia in high doses). diarrhoea. is anxiolytic which acts without interacting with BZ receptors. lethargy. NON-BENZODIAZEPINE ANXIOLYTICS — Pyrazopyridines: Etazolate and cartazolate increase the binding ability of BZ receptors. epigastric pain). paradoxical delirium. retrograde and antegrade amnesia.Psychopharmacology
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Adverse Effects The side effects of BZs include drowsiness. hostile behaviour. urinary incontinence. dependence and withdrawal syndrome. It does not potentiate the effects of alcohol. Side Effects It includes dizziness. causes less sedation.

(ii) Schizophrenia: ECT produces greater early symptomatic relief than the neuroleptics but when both are combined. — inability to take drugs e. — depression with marked retardation. sleep disturbance. — severe puerperal depression — depressive illness with nihilistic or paranoid delusions. — patients with Schizodepression. suicidal tendencies etc. the benefit is maximum.e.g. loss of appetite and weight. — depressive Stupor.g. psychomotor retardation etc.g. — in the elderly where ECT may be safer than drugs. depression in first trimester of pregnancy.) and psychotic symptoms (e. liver or renal failure. depression in physical illness e.. The combination of ECT and antidepressants has been found to produce fewer relapses at follow up. — failure to respond to an adequate course of antidepressant. delusions. feeling of guilt.). Other indications in depression are: — severe depression with suicidal risk.21
Electroconvulsive Therapy
(ECT. — inability to tolerate side effects of antidepressants. The main indications of ECT in schizophrenia are:
. also Electroshock or Shock Therapy or Electroplexy therapy) Indications The main indications of ECT include (i) Depressive illness: ECT is effective treatment in severe depressive illness especially with somatic features (i.

It can be minimised by: — using unilateral ECT. neurodermatitis. The memory loss is believed to be due to neuronal hypoxia during seizure. bodyaches and vomiting (due to temporary increase in intracranial pressure and myalgias) (ii) Confusion: It is usually slight and temporary. Prolonged confusion can be due to underlying organic illness or when duration of current or voltage was more. The memory loss is short-term and may last from a few days to few months (from 9 days to 9 months). organic mental disorders and delirium tremens.g. puerperal mania. epilepsy.Electroconvulsive Therapy
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(iii)
(iv) (v) (vi) (vii)
excitement (secondary to catatonia or delusions) stupor (catatonic) acute schizophrenic episode intolerable or resistant to drugs puerperal schizophrenia schizophrenic episode in first trimester of pregnancy schizophrenia in the presence of chronic physical illness when drugs are contraindicated — depression in the schizophrenic illness (e. at onset or in residual phase) Mania: The main indications of ECT in mania are: — excited or uncooperative behaviour — bipolar mood disorder with mixed features — bipolar mood disorder-rapid cyclers — others-mania in first trimester of pregnancy. ECT is treatment of choice. — oxygenation before and after seizure. ECT has also been tried in anorexia nervosa. — giving individualised minimal voltage and current. schizomania.
. phantom limb and trigeminal neuralgia. Pregnancy is not at all a contraindication. Postpartum psychosis: Some reports indicate that ECT is the treatment of choice in Puerperal psychosis (especially depressive or bipolar type or mixed type). (iii) Amnesia: (both retrograde and anterograde).
— — — — — — —
Side Effects (i) Headache. Schizoaffective disorders: ECT is an effective mode of treatment in patients with schizodepression. Psychosis in first trimester of pregnancy: When drugs cannot be given. — recall of major events or routines before ECT. It is also useful in psychotic patients who may have underlying mental retardation. Memory impairment that occurs with ECT is highly variable.

bronchial secretion..0% solution.6 to 1 mg intravenously at the time of giving anaesthetic agent.. The passage of electricity across the brain. Its dose is about 30 mg (0.25 gm in 10 C. The administration of an anaesthetic drug. 50 mg).Electroconvulsive Therapy
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(i) (ii) (iii) (iv) (v) (vi)
The repeated rapid induction of unconsciousness. (ii) Consent: Informed or real consent requires an understanding of the nature. — Atropine: Atropine should not be given routinely by subcutaneous or intramuscular route as a premedication unless there has been a previous problem with excess salivation.C. The dose should be adjusted as not to abolish all signs of convulsion. Considerable medical and nursing attention. The induction of bilateral grand mal epileptic seizure and neurotransmitters balance. In India.5% solution and not 5. succinylcholine is used. The main reason to give atropine is to block the vagus nerve and so protect the heart from bradycardia and arrythmias. Vagal blockade can be achieved by giving atropine sulphate 0. ECG etc.e.e.C) i.. — Muscle relaxant: A muscle relaxant i.5 mg/kg) intravenously (more dose may be required in patients with rheumatoid arthritis i. (iii) Fully physical examination: including Fundus. (iv) Testing for cerebral dominance: This should be carried out routinely on all patients who are to receive unilateral ECT. It appears that the electricity and/or epileptic fit are necessary for ECT to exert its full effect but that in non-deluded depressed patients. purpose and likely consequences of a treatment.e.
Administration of ECT (i) Explanation to the patient: Fears and fantasies about the treatment are often allayed by the facts and rarely made worse. thiopentone is commonly used (0. given over 20 to 25 seconds. a muscle relaxant and sometimes atropine. Application (i) Premedication and Anaesthetic: — Anaesthetic agent: Methohexitone sodium (0. other factors such as 1. A varied set of attitudes and expectations on the part of the patient and the family. Its main indication is to produce anaesthesia.2% solution in 5% dextrose) is the drug of choice of ECT anaesthesia. — Oxygenation: Oxygen should be given before and after the period of succinylcholine-induced apnoea. 5–10 C. 5 or 6 above may play a part. Fasting of 6–12 hours is needed. of 2.
.

How to know whether a fit has occurred — The most reliable is EEG monitoring.
. an electrical stimulus (70 to 120 volts which varies from patient to patient) for 0.190
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(ii) The Current: — After placing a mouth gag in patient’s mouth (to prevent tongue bite or lip bite).2 to 0.6 seconds is passed. — Others. apply cuff to the ipsilateral forearm. It will not become paralysed by the relaxant and will show twitchings. Most patients need 4 to 12 ECTs. It is important to clean the scalp with normal saline or jelly to decrease scalp’s resistance. When Unilateral ECT is used. The other signs such as bilateral plantar extensor. — Isolate one arm by inflating a blood pressure cuff to above systolic blood pressure before the muscle relaxant is given. reaction of pupil (if constriction and then slow dilatation) are not reliable (especially if unilateral ECT is used). Assess the patient after each ECT. Number and Frequency of Treatments A set number of treatments should not be prescribed.

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Psychological Methods of Treatment
I. PSYCHOTHERAPY

Definition Psychotherapy is the development of a trusting relationship, which allows free communication and leads to understanding, integration and acceptance of self. Common Features of Psychotherapies — An intense, emotionally charged relationship, with a person or group. — A rationale or myth explaining the distress and methods of dealing with it. — Provision of new information about the future, the source of the problem and possible alternatives which hold a hope of relief. — Non-specific methods of boosting self-esteem. — Provision of success experiences. — Facilitation of emotional arousal — It takes place in a locale designated as a place of healing. Types of Psychotherapy Psychotherapies are classified according to: (a) Depth of probing in the unconscious mind — Superficial or short-term (also known as supportive psychotherapy). — Deep or long-term (also known as analytic psychotherapy). — Educative (also known as counselling). (b) Number of patients treated in any therapeutic session (i) Individual Psychotherapy.

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(ii) Group Psychotherapy. (iii) Family Therapy. (c) Theoretical formulations used in psychotherapy (i) Supportive. Which provide support, guidance, advice and reassurance. (ii) Re-educative. Which attempt to teach the individual new patterns of behaviour and social functioning. (iii) Reconstructive. Which aim to dismantle and rebuilt a new personality. Unwanted Effects of Psychotherapy — Patients may become excessively dependent on therapy or the therapist. — Intensive psychotherapy may be distressing to the patient and result in exacerbation of symptoms and deterioration in relationships. — Disorders for which physical treatments would be more appropriate e.g. psychotic states or physical illness presenting with mental symptoms, may be missed. — Ineffective psychotherapy wastes time and money, and damages patients’ morale. Contraindications — Psychotic patients with severe behaviour disturbances like excitement. — Organic psychoses (in acute phase). — Patients who are unmotivated and unwilling to accept it. — Group psychotherapy in hysteria, hypochondriasis etc. — Patients who are unlikely to respond e.g. personality disorders (especially antisocial type), malingering etc. Commonly used Psychotherapies are I. Supportive Psychotherapy It is a form of psychological treatment given to patients with chronic and disabling psychiatric conditions for whom basic change is not seen as a realistic goal. Indications (Selection Criteria) The main indications of supportive psychotherapy include: (i) The ‘healthy’ individual faced with overwhelming stress or crises—particularly in the face of traumas or disasters. (ii) Patient with ego-deficits. (iii) Other Indications e.g. Alexithymic patients (those with a striking inability to find words to describe other emotions and a tendency to describe endless situational details or symptoms instead of feelings), Passive patients those who derive significant practical benefit, patients who are able to relate to the therapist, have past history of good interpersonal relationship, word and educational performance and use leisure time are better suited for supportive therapy.

II. Client-centred Psychotherapy It was borrowed from the ideas of Carl Rogers (1951). The term ‘client’ rather than ‘patient’ has been adopted. The main conditions include: — The client is experiencing at least a vague incongruence which causes him to be anxious. — The therapist is congruent (or genuine or real) in the relationship. — The therapist is experiencing a prizing, caring or acceptable attitude toward the patient. — The therapist is experiencing an accurately sensitive understanding of the client’s internal frame of reference. — The client perceives to some minimal degree of realness, the caring and the understanding of the therapist. The following attitudes are deemed to be most important for the success of client-centred therapy: (i) Genuineness (or Congruence) (ii) Unconditioned Positive Regard (iii) Accurate Empathy III. Cognitive Psychotherapy Definition It is a group of psychological treatments which share the aim of bringing about improvement in psychiatric disorder by altering maladaptive thinking.

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It was developed by Aaron T. Beck and his colleagues. See Table 2.
Table 2: Cognitive Processing Errors 1. Emotional reasoning: A conclusion or inference based on an emotional state; i.e., “I feel this way; therefore, I am this way.” 2. Overgeneralisation: Evidence drawn from one experience or a small set of experiences to reach an unwarranted conclusion with far-reaching implications. 3. Catastrophic thinking: An extreme example of overgeneralisation, in which the impact of a clearly negative event or experience is amplified to extreme proportions; e.g., “If I have a panic attack I will lose all control and go crazy (or die).” 4. All-or-none (black-or-white; absolutistic) thinking: An unnecessary division of complex or continuous outcomes into polarised extremes; e.g., “Either I am a success at this, or I’m a total failure.” 5. Shoulds and musts: Imperative statements about self that dictate rigid standards or reflect an unrealistic degree of presumed control over external events. 6. Negative predictions: Use of pessimism or earlier experiences of failure to prematurely or inappropriately predict failure in a new situation; also known as “fortune telling.” 7. Mind reading: Negatively toned inferences about the thoughts, intentions, or motives of another person. 8. Labelling: An undesirable characteristic of a person or event is made definitive of that person or event;’ e.g., “Because I failed to be selected for ballet, I am a failure.” 9. Personalisation: Interpretation of an event, situation, or behaviour as salient or personally indicative of a negative aspect of self. 10. Selective negative focus (selective abstraction): Focusing on undesirable or negative events, memories, or implications at the expense of recalling or identifying other, more neutral or positive information. In fact, positive information may be ignored or disqualified as irrelevant, atypical, or trivial. 11. Cognitive avoidance: Unpleasant thoughts, feelings, or events are misperceived as overwhelming and/ or insurmountable and are actively suppressed or avoided. 12. Somatic (mis) focus: The predisposition to interpret internal stimuli (e.g., heart rate, palpitations, shortness of breath, dizziness, or tingling) as definite indications of impending catastrophic events (i.e., heart attack, suffocation, collapse, etc.).

Classification of cognitive therapy (i) Techniques Intended to Interrupt Cognition. These aim to stop sequence of intrusive thoughts in the hope that thoughts will not start again immediately. Because intrusive thoughts are difficult to arrest, another technique ‘thought stopping’ is used in which a sudden, intense but short lived distraction is given, the common being just shouting aloud to stop, then the patient repeats silently; the other method used is by applying painful stimuli. (ii) Techniques intended to Counterbalance Cognitions. (iii) Techniques intended to alter cognitions. (iv) Techniques for problem solving.

g.g. — Selective abstraction. yet fails to accept that he is doing his best (Minimisation). 5.g. Set the agenda Weekly items Review of events since last session Feedback on reactions to previous session and review of key points Homework review 4. — Alcoholic patient. bulimia nervosa) — Problems involving bereavement. teacher in his class sees two students bored. — A depressed patient makes a great effort to help his friend in trouble. e. Today’s major topic Set homework for next week Summarise key points of today’s session Feedback on reactions to today’s session
. — Phobias (especially agoraphobia) — Eating disorders (e. — Overgeneralisation e.g. low self-regard. e. 2. self-blame. thinks that his employer has noticed it and he will be terminated of the job (Magnification).
Table 3: Structure of a Typical Cognitive Therapy Session 1. Technique See Table 3. 6. — Magnification or minimisation. patient sees a friend in the street who fails to acknowledge him. feels his class is not liked by all the students. e.g. redundancy at work etc. 7. self-criticism.Psychological Methods of Treatment
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Applications Depressive Disorder (i) Intrusive Thoughts e. (ii) Cognitive disorders — Arbitrary inference. divorce. anorexia nervosa. A mother spoiling a dish feels that she is a bad mother. Other Indications — Anxiety neurosis. 3. he thinks his friends do not like him any more.g. Mood check Examine symptom severity scores from a questionnaire such as the Beck Depression Inventory. person commits an unimportant error.

treatment is given to both partners in a marriage. — Extramarital relationships. — Poor communication problem. marital therapy employ varied. refers to a broad range of treatment modalities that attempt to modify the marital relationship with the goal of enhancing marital satisfaction or correcting marital dysfunction. — Presence of covert marital disorder in form of symptomatology or dysfunction in one of the spouses or the children. learning and communicational systems theory to achieve the goal whereas marriage counselling includes a very broad range of disharmony.e. — Family functioning cannot be fully understood by simply understanding each of the parts. Marital Therapy: In marital therapy. — Transactional pattern of the family system shapes the behaviour of family members.
. Definition: Marital therapy. — Lack of commitment to continuation of the marriage.196
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IV. The term ‘couple therapy’ is sometimes used. — A family’s structure and organisation are important factors determining the behaviour of family members. Contraindications — Premature exposure of the spouses to marital secrets such as homosexuality. V. — Eruption of symptoms in a family member coincides with the outbreak of marital conflicts. — One part of the family cannot be fully understood in isolation from the rest of the system. — The parts of the family are interrelated. — If the spouses use the sessions consistently to attack each other. Marital therapy differs from marital counselling on theoretical and technical basis i. — When individual therapy has failed or is unlikely to succeed due to poor motivation or limited ability to communicate with the therapist. the treatment of marital relationship. Family Therapy History: Nathan Ackerman developed the idea of family therapy as a result of his experience in the psychotherapy of children. extensive assessment techniques and utilise the systematic knowledge of personality. — When there is danger of marital instability due to improvement of a mentally ill patient or when the healthy “spouse” develops symptoms.. General principles: The essential features of family therapy are the following concepts. criminal involvement. Indications — Presence of overt marital conflicts that result in recognisable suffering of both spouses.

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Indications Family therapy has been used in all types of psychiatric problems including the psychoses, reactive depression, anxiety neurosis, psychosomatic illness, substance abuse and various childhood psychiatric problems. Contraindications — Lack of adequately trained therapist (only true contraindication) — Poor motivation — Fixed character pathology e.g. lying, physical violence. — Extreme secrecy. VI. Group Psychotherapy: In 1919, L. Cody Marsh applied the group method of treatment to institutionalised mental patients. Definition Group psychotherapy is a form of treatment in which carefully selected emotionally ill persons are placed into group, guided by a trained therapist for the purpose of changing the maladaptive behaviour of the individual member. Patient Selection Inclusion Criteria — Ability to perform the group task. — Problem areas compatible with goals of group. — Motivation to change. — Patients with authority anxiety (especially adolescents). — Patients using defense mechanisms of projection, repression, denial, suppression, transference reactions. Exclusion Criteria — Marked incompatibility with group norms for acceptable behaviour. — Inability to tolerate group setting (Peer anxiety). — Severe incompatibility with one or more of the other members. — Tendency to assume deviant role. Special Indications The main uses of group therapy include — Schizophrenia — Mood Disorders — Paranoid States — Neuroses (Anxiety Neurosis, Phobic Disorders)

A. BEHAVIOUR THERAPY Definition It is the systematic application of principles of learning to the analysis and treatment of disorders of behaviour. Learning It is defined as any relatively permanent change in behaviour which occurs as a result of practice or experience. Behaviour Strictly speaking behaviour refers to the organism’s skeletal muscle activity in humans, both what they do (motor behaviour) and what they say (verbal behaviour). I. Classical Conditioning (CC) Ivan P. Pavlov (1849–1936): Pavlovian or respondent conditioning. The essential operation in classical conditioning (CC) is a pairing of two stimuli. A neutral conditioned stimulus (CS) is paired with an unconditioned stimulus (US) that evokes an unconditioned response (UR). As a result of this pairing, the previously neutral conditioned stimulus begins to call forth a response similar to that evoked by the unconditioned stimulus. After learning, when the conditioned stimulus produces the response, the response is called a conditioned response (CR). Terms used Extinction: The weakening of a conditioned response occurs in CC when the CS is repeatedly presented without the US. Stimulus generalisation: Tendency to give CR to stimulus which are similar in some way to the CS but which have never been paired with the passage of time. Discrimination: Process of learning to make one response to one stimulus and another response or no response to another stimulus. Classical conditioning (CC): With respect to human behaviour, CC seems to play a large

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role in the formation of conditioned emotional responses the conditioning of emotional states to previously neutral stimuli. II. Operant Conditioning (OC) (By B.F. Skinner, 1904–1990). In OC, a reinforcer in any stimulus or event which when produced by a response, makes that response more likely to occur in future. The major principle of OC is that if a reinforcement is contingent upon a certain response, that response will become more likely to occur. Terms used Shaping: Process of learning a complex response by first learning a number of similar responses which are steps leading to the complex response. Extinction: In OC, extinction of learned behaviour—a decrease in the likelihood of occurrence of the behaviour is produced by omitting reinforcement following the behaviour. Stimulus generalisation: Same as in CC. Discrimination: Develops in OC when differences in the reinforcement of a response accompany different stimuli. Continuous reinforcement: Reinforcement follows every occurrence of a particular response called continuous reinforcement. Primary reinforcer: In OC, it is one which is effective for an untrained organism: no special previous training is needed for it to be effective. Secondary reinforcer: Is a learned reinforcer; stimuli become secondary reinforcer; stimuli which become paired with primary reinforcers. Positive reinforcer: It is stimulus or event which increases the likelihood of a response when it terminates or ends, following a response. — Praise is the easiest one — Reinforce the reinforcers. Negative reinforcers: Are noxious or unpleasant, stimuli or events which terminate when contingent upon the appropriate response being made. Escape learning: The acquisition of responses which terminate noxious stimulation—is based on negative reinforcement. Punisher: In contrast to negative reinforcement, a punisher is a noxious stimulus that is produced when a particular response is made. Punishers decrease the likelihood that a response will be made and thus involved in learning what not to do. Classical Conditioning versus Operant Conditioning (CC versus OC) — In OC reinforcement is contingent on what the learner does while in CC reinforcement is defined as the pairing of the conditioned and unconditioned stimuli and is not contingent on the occurrence of a particular response.

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— The responses which are learned in CC are stereotyped, reflex like ones which are elicitated by the unconditioned stimulus while in OC response is voluntary. — In CC—consequences of behaviour are relatively unimportant while in OC they are important. III. Cognitive Learning Cognitive learning is learning in which without explicit reinforcement, there is a change in the way information is processed as a result of some experience a person or animal has had. Behaviour Therapy versus Psychoanalysis — Behaviour therapy asserts that the symptom is the illness and not that there is any underlying process or illness of which the symptoms are merely superficial manifestations. — Behaviour therapy is applicable to unwilling patients. Principles of Behaviour Therapy — Close observation of behaviour. — Concentration on symptoms as the target for therapy. — General reliance on principles of learning. — An empirical approach to innovation. — A commitment to objective evaluation of efficacy. Indications of Behaviour Therapy (BT) It is a treatment of choice in — Phobias — Compulsions — Nocturnal enuresis — Social anxiety states — Sexual dysfunctions — Tension headaches — Tics — Obesity — Anorexia nervosa. Also used to modify — Maladaptive habits — Sexual role disturbances — Psychosomatic reactions — Smoking — Drinking

rehabilitation of physically handicapped children. Thought stopping is sometimes used in the control of obsessional thoughts by arranging a sudden intrusion. (c) Shaping: The successive approximations to the required behaviour with contingent positive reinforcement. (b) Flooding: Flooding involves exposing patients to a phobic object or situation in a nongraded manner with no attempt to reduce anxiety. which holds that prior establishment of an appetitive physiological response can prove capable of blocking a conditioned avoidance response. Unlike systematic desensitisation. usually by inflicting pain in association with a stimulus. It is useful in many other types of situations e. 1969): It refers to the acquisition of new behaviours by the process of imitation.Psychological Methods of Treatment
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Contraindications of BT Those psychiatric disorders in which symptomatology in acute.g. (e) Response prevention and restraint: When combined with flooding. 1958): It is based on the principle of reciprocal inhibition. no prior relaxation techniques are taught to the patient and it is usually given in a nongraded manner or in reverse hierarchy (starting from most phobic to least phobic stimulus). it is extensively used. etc. Systematic desensitisation as given by Wolpe (1958) involve the following three stages: (i) Training the patient to relax (ii) Constructing with the patient a hierarchy of anxiety-arousing situation. In phobic neurosis. Flooding is avoided in patients with cardiovascular disorders or uncooperative patients or those who continue to have panic attacks. It can be conducted in imagination (Implosion) or in vivo. (d) Modelling (Bandura et al. children with neurotic behaviour or autism. pervasive or non circumscribed and in which triggering environmental events or external reinforcement are not obvious or capable of definition. whilst the patient inhibits the anxiety by relaxation.. (f) Aversion: It involves producing an unpleasant sensation in the patient.
. In this form of treatment. it is the treatment of choice in obsessive compulsive neurosis. such as soiled towel and subsequently preventing him from carrying out his usual cleansing ritual. Aversion therapy has been used for alcoholism and sexual perversions. the patient observes someone else (may be the therapist) carrying out an action which the patient currently finds difficult to perform. (iii) Presenting phobic items form the hierarchy (a sequence of phobic stimuli in an increasing order) in a graded way. The technique involves exposing the patient to a contaminating object. Techniques (a) Systematic desensitisation (Wolpe.

Earlier. Later. thumbsucking. socially anxious and inhibited in the expression of warm feelings of anger. Dharana and Samadhi). a patient with bulimia nervosa. it is being reinforced by certain of its consequences and if these consequences can be altered.
. the practice of yoga was to attain spiritual and mystic goals. tics. (o) Contracts: It is often the case that the reinforcing consequences of a patient’s behaviour are under the control of another person. which conceived of the world. yoga was practiced as a psychophysiological technique for voluntary control and for integrating the body and the mind. The spiritual approach. (3) breathing exercises (Pranayama). (h) Contingency management: This group of procedure is based on the principle that if behaviour persists.D. The worldly approach describes it as the union between the mind and the body. nailbiting etc. on the other hand. many yogic procedures have been developed in India. Yoga and Meditation The term “Yoga” is derived from the root word “Yuj. — Self evaluation: It refers to making records of progress and this also helps to bring about change. Based on this broad conceptual framework. the Atman. The philosophical explanation was cited in the Vedas and Upanishads. regards it as the union between the individual self and the cosmic self. 1958): Used in chronically depressed. The basic components of all different yogic schools are: (1) yogic teachings (Yama and Niyama). (l) Social skills training: Discussed later in this chapter. stammering. (2) Kriyas.” meaning union. Token Economy: When reinforcement is mainly by tokens to be exchanged for privileges.g. (n) Hypnosis and abreaction: Discussed with psychotherapy. Bhanda and Mudra (Asana). Premack principle: Any frequently performed piece of behaviour can be used as a positive reinforcer of the desired behaviour. the behaviour should change.202
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(g) Self-control techniques — Self Monitoring: It refers to keeping daily records of the problem behaviour and the circumstances in which it appears. can be reduced when the patient deliberately repeats the behaviour. e.) in his “Yoga Sutra”. as a conscious spiritual principle permeating all things. (j) Negative practice (Dunlap. yogic postures. The systematisation of this knowledge and practice was formulated by the great Indian seer Patanjali (200 A. (k) Biofeedback: Discussed later in this chapter. (i) Assertiveness training (Wolpe.g. and (4) meditations (Dhayana. 1932): Some problems e. (m) Cognitive therapy: Discussed with psychotherapy.

Yoga therapy has been tried in psychiatric as well as psychosomatic disorders such as anxiety neurosis. and Meditation. Meditation and Psychotherapy Appraising Indian philosophical systems in general and the yoga system in particular. Pranayama and Samyama meditation. bronchial asthma. and total solids in urine. acidity. Asanas. and most of the studies compare yoga with behavioural techniques. and self-worth and better emotional and home adjustment. loving kindness towards oneself and others. interpersonal relations. transformative insight into emotional conflicts. In contrast. Pranayama.Psychological Methods of Treatment
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Recently. and reciprocal inhibition are considered to be similar to Shavasana. Psychophysiological Correlates of Meditation and Yoga Later researchers hypothesised that meditation produces a “hypometabolic state”. Certain behavioural methods such as progressive relaxation. and increased coherence of electrical activity of the brain. and volume. revealed significant alterations in physiological functions. locus of control. corticosteroid metabolites. yoga is seen from a behaviourist viewpoint. autogenic training. hypertension. Wolberg observed that yogic approaches are a combination of supportive and educational modalities. relaxed nature. decreased blood pressure. The procedures in yoga such as Yama and Niayama are like the stimulus control and response control aspects of the environment. Studies of full yogic practices showed an increase in muscular. with such changes as decreased oxygen consumption. increased skin resistance. and visual and auditory reaction time were improved with the yoga practice. time. depression. Psychophysiological Correlates of Yoga Studies on yoga practice. access to previously unconscious material. Psychological Correlates of Meditation and Yoga The major findings were an increase in self-actualisation. yoga has been recognised worldwide as a treatment procedure. Yoga and Behavioural Therapy In the West. and changes in the experience of personal identity. Several studies of yoga have found an increase in plasma proteins. inner directedness. competency. plasma cholinesterase. transpersonal theorists contend that meditation may provide inner calm. psychogenic headache.
. Cognitive functions like immediate memory. which are used in selfcontrol procedures of behavioural therapy. visuomotor coordination. which included Kriyas. cardiovascular and respiratory efficiency and decreased blood pressure and heart rate. diabetes etc. A decreasing trend in blood sugar and specific gravity of urine was observed with the practice of yogic exercises and pranayama.

Since yoga is grounded in a cultural-religious milieu. Recent reports on bronchial asthma showed such promising results as an increase in vital capacity. As opposed to drugs. BIOFEEDBACK AND BEHAVIOURAL MEDICINE Behavioural medicine is a term introduced by Birks in 1973. these have the advantage of being inexpensive. devoid of side effects. or meditation but also yogic diet. faith. easily accessible. peak expiratory flow. breathing exercise. Theory Feedback from the environment about the consequences of one’s acts provides the rewards and punishments that are an important part of learning. diagnosis. obsessive compulsive disorder. it involves not only postures. Definition Behavioural medicine is the interdisciplinary field concerned with the development and integration of behavioural and biomedical science knowledge techniques relevant to health and illness and the application of this knowledge and these techniques to prevention. and a way of spiritual living. and useful in preventive and promotive roles. neurotic depression. treatment and rehabilitation. and a decrease in medication requirement. Applications of Psychophysiologic Problems for which a Single Biofeedback Modality is Useful (a) Thermal Feedback (applied to circulatory and sympathetic nervous system disorders) — Migraine Headache — Raynaud’s Disease — Buerger’s Disease (b) EEG Feedback (applied to central nervous system problems) — Epilepsy (GME) — Creativity Enhancement — Narcolepsy (c) EMG Feedback (applied to disorders involving muscle function) — Tension Headache — Neuromuscular Re-education — Cerebral Palsy (symptomatic relief) — Bruxism
. B. or involutional depression whereas less effective results are seen with schizophrenia and personality disorders.204
Psychiatry for General Practitioners
Effect of Meditation and Yoga in Neurotic and Psychosomatic Illnesses Significant improvement has been reported in patients with anxiety reaction.